Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 57111 | 7 May 2024 15:50:00 | The following was received from the Texas Department of State Health Services (the Department) via email: On May 7, 2024, the Department was notified by the licensee that on May 1, 2024, one of its radiography crews was unable to fully retract a 82.92 curie iridium-192 source into a QSA 880D exposure device. The radiographers had cranked the source out to test a weld, but when they tried to retract the source back to the fully shielded position they could not. The radiographers immediately notified the licensees site radiation safety officer (SRSO), set up new barriers, and warned other individuals in the area. After a licensee manager arrived at the location, it was determined that a bend in the guide tube was too sharp to allow the source to be retracted. Using a set of 6.5 foot tongs, the SRSO repositioned the guide tube, and a radiographer was able to return the source to the fully shielded position. No individual received an exposure that exceeded 100 millirem. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 10104 Texas NMED Number: TX240014 |
| ENS 57082 | 18 April 2024 18:18:00 | The following was received from the Texas Department of State Health Services (the Department) via email: On April 18, 2024, the Department was notified by the licensee that the shutter on a Vega model SH-F1 nuclear gauge failed to close. The gauge contains a 20 millicurie (original activity) cesium - 137 source. Open is the normal position for the gauge shutter. The licensee reported there is no risk of additional radiation exposure to members of the general public or radiation workers, due to this failure. The manufacturer has been contacted to repair the gauge shutter. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 10100 Texas NMED Number: TX240013 |
| ENS 57080 | 17 April 2024 10:34:00 | The following was received from the Texas Department of State Health Services (the Department) via email: On April 16, 2024, the Department was notified by the licensee that they had removed a Natco model B-20-06 nuclear gauge containing a 175 millicurie (original activity) Cs-137 source from a vessel to allow work on the vessel. The gauge shutter was in the closed position and was functioning normally. Dose rates taken at the gauge before removal were normal at 0.65 millirem per hour. After the gauge was removed from the vessel, it was placed on a pallet with other gauges that had been removed from the vessel. At this time, the licensee performed additional radiation surveys, and the dose rate taken within a foot at the top of the gauge shutter was now reading 8.65 millirem per hour. The gauges were all moved to a locked storage location. The licensee has contacted a service company to inspect the gauge and determine the cause for the increased dose rates. The licensees radiation safety officer (RSO) stated the shutter may have been damaged as the gauge was being moved to the pallet. The RSO stated no overexposures had occurred. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: 10099 Texas NMED No.: TX240012 |
| ENS 57052 | 26 March 2024 14:15:00 | The following was received from the Texas Department of State Health Services (the Department) via phone and email: On March 26, 2024, the Department was notified by the licensees radiation safety office (RSO) that earlier this day a radiography crew had a source disconnect while using a SPEC 150 exposure device. The device contained a 23 curie, iridium-192 source. The disconnect occurred on the first shot of the day. The RSO reported that the radiographers had completed set up for the first shot but had failed to properly connect the guide tube to the camera. When the radiographers cranked the source out and it hit the collimator, the guide tube popped loose from the camera. The radiographer immediately attempted to crank the source back into the camera but when the source reached the end of the guide tube the source pigtail disconnected from the drive cable. The radiographers set up new boundaries and contacted the RSO. An RSO from a nearby office responded to the location. The RSO was wearing a self-reading dosimeter (SRD), alarming rate meter, and TLD (thermoluminescent dosimeter) exposure badge. The RSO placed the camera on the source for shielding, attached the source back to the drive cable, and retracted the source into the camera. The responding RSOs SRD was reading off scale after retracting the source. The badge has been sent to the licensees dosimetry processor for emergency processing. The licensee does not believe any individual exceeded any limit due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident # 10095 |
| ENS 57020 | 11 March 2024 12:13:00 | The following was received from the Texas Department of State Health Services (the Department) via email: On March 11, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that an event at the facility resulted in molten metal being spewed out from the furnace. Some of the molten metal landed on the housing cover of a Berthold LB 300 gauge containing a 2.5 curie (original activity 3 years ago) source. The licensee was able to remove the cover and inspected the gauge. The licensee found that some of the molten metal had leaked on to the shutter operator for the gauge, preventing the shutter from closing. The RSO stated they were able to remove the gauge from the vessel and place in a storage area. The RSO stated the room has been locked and posted to prevent inadvertent entry. The RSO stated they had performed radiation surveys outside the storage room and readings obtained were less than 2 millirem per hour. The RSO stated no individual received any radiation exposure that would have exceeded any limit. The RSO stated they have contacted a service provider to repair the gauge. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: 10094 Texas NMED No.: TX240009 |
| ENS 57008 | 5 March 2024 17:28:00 | The following information was provided by the Texas Department of State Health Services (the Department) via email: On March 5, 2024, the Department was notified by the licensee that during routine shutter testing, the shutter on a Vega SH-F2C failed to close. Open is the normal operating position for the gauge shutter. The gauge contains a 500 millicurie (original activity) cesium-137 source. The gauge is in an area that is accessed only to test the shutter as it is located 230 feet off the ground. The gauge does not present an exposure risk to any individual. The licensee has contacted a service company to repair the gauge. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 10093 NMED Number: TX240008 |
| ENS 56982 | 20 February 2024 16:10:00 | The following report was received via phone call and email from the Texas Department of State Health Services (the Department): On February 20, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that a Troxler 3440 moisture/density gauge was damaged at a temporary job site. The gauge contains a 40 millicurie americium - 241 source and an 8 millicurie cesium -137 source. The gauge operator was setting the gauge up for use when they noticed that a large number of construction equipment was moving into the area. The operator decided to move their truck out of the way and while they were doing so the gauge was struck by a piece of equipment. The RSO stated the gauge case was damaged, but the sources were not damaged. The cesium source was still in the fully shielded position when the event occurred. The RSO stated the gauge was transported back to their facility and a leak test was conducted on the sources. The RSO stated they have contacted a service company and as soon as they get the leak test results back, they will dispose of the gauge. No individual received any significant exposure due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 10089 Texas NMED Number: TX240007 |
| ENS 56902 | 20 December 2023 13:05:00 | The following report was received via phone and email by the Texas Department of State Health Services (the Department): On December 20, 2023, the Department was notified by the licensee's radiation safety officer (RSO) that on December 19, 2023, they were unable to retract a 52 curie iridium-192 source into a QSA 880D exposure device. The RSO stated its radiographers were performing radiography on a pipe. The pipe fell and struck the guide tube, crimping it far enough to prevent them from retracting the source. The radiographers isolated the area and contacted the RSO. A retrieval team arrived at the location and was able to retract the source. The RSO stated no individual exceeded any exposure limits. Additional information will be provided as it is receive it accordance with SA-300. Texas Incident Number: 10074 Texas NMED Number: TX230058 |
| ENS 56883 | 8 December 2023 21:35:00 | The following information was provided by the Texas Department of State Health Services via email: On December 8, 2023, the licensee's radiation safety officer (RSO) reported a Troxler 3430 plus gauge was damaged at a job site. The gauge contains a 40 millicurie AmBe (americium-beryllium) source and an 8 millicurie cesium-137 source. The RSO stated that a technician was using the gauge in a trench to test soil compaction. The technician had completed a reading and was reporting the reading to another contractor outside the trench when the soil compacter was moved and struck the gauge. The soil compacter was moved back, and the technician went to the gauge. The only damage appeared to be to the plastic part of the case. The cesium source was in the fully shielded position. The RSO stated that the operating rod appeared to be operating properly. Dose rates at 3 feet from the gauge were 0.1 millirem per hour. The RSO stated that the gauge will be taken to their storage location and marked 'DO NOT USE.' The RSO stated that the gauge will be delivered to a service company on December 11, 2023, for inspection. No individual received an exposure that would exceed any limit. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 10072 Texas NMED Number: TX230057 |
| ENS 56855 | 15 November 2023 16:40:00 | The following information was provided by the Texas Department of State Health Services (the Department) via phone and email: On November 15, 2023, the Department was notified by the licensee that a Troxler model 3440 moisture/density gauge had been lost. The gauge contains one 8 millicurie Cs-137 source and one 40 millicurie Am-241 source. The radiation safety officer (RSO) stated that on November 14, 2023, a licensee technician was performing work at a temporary job site where testing was being performed periodically. While sitting in their truck with the gauge on the tailgate of the truck, the technician realized they needed to go to a second job site about 20 minutes from where he was. When they reached the second job site, the technician realized they had left the gauge on the tailgate. The technician notified the licensee's RSO and the licensee conducted multiple searches for the gauge but did not locate the gauge. The RSO was advised to contact local law enforcement about the event. The RSO was advised to check local pawn shops and internet sites such as eBay and Craig's List to watch for the gauge. The RSO does not believe the gauge possesses an exposure risk to any individual. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 10066 NMED Number: TX230052 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 |
| ENS 56843 | 9 November 2023 13:45:00 | The following information was provided by the Texas Department of State Health Services (the Department) via phone and email: On November 9, 2023, the Department was notified by the licensee that a shipment of 960 millicuries of iridium - 192 Zero Wash had not arrived at its Alice, Texas, location. The licensee stated the shipment was scheduled to arrive in Alice, Texas on October 31, 2023. The licensee stated that the carrier used often misses the arrival date by as much as a week, so they did not start looking for the shipment until November 7, 2023. The licensee contacted the shipping company and the last know location of the shipment is Abilene, Texas. The shipper is searching that location for the material. The licensee stated the material was shipped inside a 55 gallon drum. It is currently believed that it is not likely that any individual would exceed any exposure limits. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number 10065 Texas NMED Number: TX230051
The following update was provided by the Texas Department of State Health Services via email: On November 9, 2023, the licensee reported they had located the missing shipment of 960 millicuries of iridium - 192 Zero Wash. The licensee had placed two orders for the materials for two separate locations and the shipping company had inadvertently delivered both shipments to the same location. Notified R4DO (Warnick), and NMSS Event Notifications, ILTAB, and CSNS Mexico via 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 |
| ENS 56833 | 4 November 2023 23:16:00 | The following information was provided by the Texas Department of State Health Services (the Department) via email: On November 4, 2023, the Department was notified by the licensee that one of its technicians had lost a Troxler 3430 moisture/density gauge. The gauge contains one 40 millicurie Am-241 source and one 8 millicurie Cs-137 source. The licensee reported that a technician was waiting in their truck to perform a test at a temporary job site when they were told by the job supervisor that the work was done for the day. The technician drove home and when they reached their home, realized they had left the gauge, which was inside its transportation box, sitting on the tailgate of the truck and it was now missing. The licensee did not know if the cesium source rod or transport case was locked. The technician retraced their route twice, but it was already dark, and they did not see the gauge. The technician notified his radiation safety officer that they had lost the gauge. The licensee will notify local law enforcement of the event. The licensee stated they will begin searching for the gauge as soon as it is light out. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-10064 Texas NMED Number: TX230050
On November 5, 2023, the Department contacted the licensee and requested the status of the gauge. The licensee stated that they had performed additional searches for the gauge this morning but did not find the gauge. The licensee stated they had contacted the Harris County, Texas, Sheriff's Department. The licensee stated they would offer a reward for the gauges return. The licensee was advised to contact local pawn shops and watch social media platforms like eBay and Craig's List. The licensee was advised to contact local fire departments about the gauge and provide its contact information. The licensee stated the gauge was labeled with its contact information. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Roldan-Otero), NMSS Events Notification, ILTAB, and CNSNS (Mexico) via email
On January 4, 2024, the Department was notified by the licensee that a Troxler gauge identical to the one they had lost was on the Facebook Marketplace website. The Department contacted the Federal Bureau of Investigation Special Agent (FBISA) it has worked with previously and shared the information. On January 5, 2024, the FBISA worked with the licensee and was able to set up a meeting with the seller and was able to recover the gauge. (The FBISA confirmed by serial number it was the gauge that was stolen). The licensee returned the gauge to its secured storage location and will perform radiation and leak test on the gauge. The individual who had the gauge stated they did not know it contained radioactive material. They also stated they never manipulated the source rod. Additional information will be provided as it is received in accordance with SA300. Notified R4DO (Drake), NMSS Events Notification, ILTAB, and CNSNS (Mexico) via 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 |
| ENS 56807 | 20 October 2023 16:52:00 | The following information was provided by the Texas Department of State Health Services (the Department) via email: On October 20, 2023, the Department was notified by the licensee's radiation safety officer (RSO) that a 52 millicurie (current activity) strontium - 90 source could not be returned to the fully shielded position in a Novoste brachytherapy device. The source had been retracted from the patient, therefore the patient had received the prescribed dose. The therapist followed the licensee's emergency procedure and placed the device into a plastic box and took it to their hot lab. Once in the hot lab, they were able to fully retract the source. The device has been taken out of service. The RSO stated the vender has been notified of the event. No overexposures occurred due to this event. Texas Incident Number: 10060 Texas NMED Number: TX230048 |
| ENS 56873 | 28 November 2023 16:10:00 | The following information was provided by the Texas Department of State Health Services (the Department) via email: A Houston police officer was driving by a scrap yard on October 16, 2023, when his (personal radiation detector) PRD alarmed. He contacted his office, and another officer with radiation detection equipment went to the location and determined the radionuclide to be cesium-137. This officer contacted the Department, and on October 17, 2023, a Department investigator went to the location and located a box in a remote section of the scrap yard. The 4 foot by 4 foot by 4 foot box had several devices that appeared to be nuclear gauges in it. A service provider was contacted by the Department and put in contact with the property owner. The service provider responded to the location to remove the gauges and determine the source of radiation. Access to the area was restricted and controlled by the property owner. It does not appear that any individual would have exceeded an exposure limit. The service provider was able to determine that there was one source in the box. The source was placed in the back of a trash truck and shielded with all of the empty source holders stacked around it. The source holders all had the radioactive materials information removed. On October 19, 2023, a second service provider went to the site to retrieve the source. While there, they found three more shields in another area of the facility that were suspected to have sources that were very well shielded. All four sources (shields) were taken to the service provider's facility. The service provider removed the 4 sources. The service provider reached out to other individuals in an attempt to identify the manufacturer. It was determined that the sources were made by 3M and sold to Ronan Engineering, who then sold them to a DuPont plant in Wilmington, NC in 1992. The North Carolina program was contacted, and they reported that license was terminated in April of 2014. The sources were sent to a facility in South Carolina. The South Carolina program was contacted, and they provided a document showing the sources had been transferred to a Texas licensee in Sugar Land, Texas. The Texas licensee closed its facility and shipped all the sources they had for disposal. The last shipment of sources with this activity level was shipped from that facility in March of 2019. The contractor used to dispose of the sources has been contacted and will attempt to determine how the sources could have ended up at the scrap yard. The Department will provide updated information as it is received. Texas Incident Number: 10058 Texas NMED Number: TX230055 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 |
| ENS 56756 | 24 September 2023 19:12:00 | The following information was provided by the Texas Department of State Health Services (the Department) via email: On September 24, 2023, the Department was notified by the licensee that during a maintenance inspection, the shutter on a Ronan Engineering nuclear gauge failed to close. The gauge contains a 500 millicurie Cs-137 source. Open is the normal operating position for the gauge. The licensee stated that due to the location of the gauge it is not an exposure risk to any individual. The licensee is posting a sign at the access port to the vessel the gauge is attached to stating `NO ENTRY.' Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-10054 |
| ENS 56735 | 13 September 2023 07:28:00 | The following information was provided by the Texas Department of State Health Services (the Department) via email: On July 13, 2023, the Department was contacted by the Biomeric's quality assurance scientist, who stated she could not find two generally licensed devices. The devices are P-2024-1000 static eliminators. The devices were used to remove static electricity on small plastic parts. The devices were discovered missing during an inventory of devices that were to be replaced. The company stated the devices did not pose a risk of exposure to any individual. The company searched for the devices, but was unable to locate them. The company has implemented a monthly inventory program to keep better track of the devices. The devices will be centrally located when in storage from now on. Texas Incident Number: 10039 Texas NMED Number: TX230034 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 |
| ENS 56732 | 10 September 2023 15:31:00 | The following report was received via telephone and email by the Texas Department of State Health Services (the Department): On September 10, 2023, the Department was notified by the licensee's radiation safety officer (RSO) that while testing a MDS Nordion Model Eldorado 8 teletherapy unit, the 1,000-curie cobalt 60 source became stuck in the unshielded position. The RSO stated that room has been isolated and the dose rates taken outside the room do not create an exposure risk to any individuals. The RSO stated that a request for service has been sent to a service contractor. Access to the room has been posted to prevent inadvertent entry into the room. The licensee will update the Department as soon as the plans for corrective actions have been completed. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 10049 Texas NMED Number: TX230040
On September 12, 2023, the Department was notified by the licensee that the source had been returned to the fully shielded position by a service provider. The licensee stated the individual retracting the source received less than 10 millirem during the process. The service provider is trying to determine the cause for the failure. Additional information will be provided as it is received IAW SA-300." Notified R4DO (Warnick) and NMSS_Events via email. |
| ENS 56728 | 8 September 2023 10:27:00 | The following was received from the Texas Department of State Health Services (the Department) via phone and email: On August 10, 2023, the Department was notified by the licensee that during the August 9, 2023, inventory of the ExxonMobil (EM) Beaumont Polyethylene Plant (BPEP) Tritium (H-3) exit signs, 9 uninstalled signs previously stored in the (instrumentation and electrical) shop could not be located. After an investigation and questioning of the personnel with access to the signs it was determined the box of tritium exit signs was placed in the trash dumpster during cleanup of the (instrumentation and electrical) shop area. As of August 14, 2023, the signs are considered missing/lost. The general licensee stated there is no evidence the integrity of the signs was compromised during the cleanup and thus there was no radiation exposure to personnel. All other unused exit signs were moved to a secured storage location. The Department has requested additional information from the general licensee. The investigation into this event is ongoing. Additional information will be provided as it is received in accordance with SA-300. The signs contained a total of 234.9 Ci, H-3 when manufactured in 2016. Texas Incident Number: 10047 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 |
| ENS 56668 | 8 August 2023 19:04:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On August 8, 2023, the Agency was notified by the licensee's service provider that the shutter on a Vega America SH-F2 nuclear gauge would not close. Open is the normal position for the gauge. The gauge contains a sixty millicurie (original activity) Cs-137 source. The source is mounted in an elevated location that prevents exposures to any personnel. The service provider stated the licensee had just completed maintenance in the vessel where the gauge was mounted and was opening the shutter when they began to feel resistance to movement. The licensee continued to open the shutter and as they reached the open position the screws holding the operating arm in place broke. The operating arm no longer operates the shutter. The licensee will contact a service provider to repair the gauge. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: 10044 |
| ENS 56578 | 15 June 2023 20:38:00 | The following information was provided by the Texas Department of Health Services (the Agency) via email: On June 15, 2023, the Agency was notified by the licensee that during routine shutter checks, the shutters on two Berthold model LB7442 nuclear gauges were stuck in the open position. The gauges both contain a 20 millicurie (original activity) cesium - 137 source. Open is the normal operating position of the gauges. There is no risk of additional radiation exposure to members of the general public or radiation workers due to this failure. The investigation into this event is ongoing. Additional information will be provided as it is received in accordance with SA-300. TX incident number: I-10026 |
| ENS 56533 | 23 May 2023 15:00:00 | The following information was provided by the Texas Department of State Health Services (the Agency) via phone and email: On May 23, 2023, the Agency was notified by the licensee's radiation safety officer (RSO) that while conducting routine shutter checks, the shutter for a Thermo Fisher model 5190 gauge was missing. The shutter is a block of lead that slides across the radiation beam. The RSO stated they believe the lead block (shutter) must have vibrated off the slide. The gauge has been removed and placed in storage and will be disposed of. The gauge contains a 200 millicurie (original activity) (Cs-137) source. No individual received an exposure that exceeded any limit. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: 10022 Texas NMED No.: TX230025 |
| ENS 56514 | 10 May 2023 13:20:00 | The following information was received via email from the Texas Dept. of State Health Services (the Agency): On May 9, 2023, the Agency was notified by the licensee that a medical event occurred earlier that day. The licensee stated a patient was prescribed two doses of SIR-Spheres yittrium-90 (Y-90). After the procedure, it was determined that the patient received doses differed from the prescribed doses by more than 20 percent. The patient was prescribed doses of 14.5 mCi and 21.7 mCi. The patient received 5.3 mCi (for the syringe dose of 14.2 mCi) and 12.31 mCi (for the syringe dose of 21.5 mCi). Delivered doses differed by 37.3 percent and 57.2 percent respectively. The prescribing physician and patient were notified of the error. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: 10017 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. |
| ENS 56392 | 7 March 2023 17:21:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On March 7, 2023, the Agency was notified by the licensee that the shutter on a Vega SH-F2 nuclear gauge had failed in the open position during routine testing. The gauge contains a 300 millicurie (original activity) Cs-137 source. Open is the normal operating position for the gauge. The licensee has contacted the manufacturer for repairs to the gauge. The licensee stated the gauge does not create an exposure risk to any individual as the gauge is located 300 feet in the air on the side of a vessel. Additional information will be provided as it is received in accordance with SA-300. Texas event report number: 56392
On March 8, 2023, the Agency was notified by the licensee that while performing routine shutter inspections a second gauge shutter was found in the stuck open position. The gauge is a Vega model SHF2C gauge containing a 500 millicurie (original activity) cesium-137 source. Open is the normal operation position for the gauge shutter. The licensee has contacted the manufacturer for repairs. The gauge does not create an exposure risk to any personnel. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Heather Gepford), NMSS Events Notification. |
| ENS 56291 | 31 December 2022 22:02:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On December 31, 2022, the Agency was notified by the licensee that while returning an exposure device to the storage location, the driver of the licensee's vehicle hit a pedestrian who was in the road picking up some material. The radiographer stated the vehicle in front of them threw on its brakes and the radiographer swerved to miss them and hit the pedestrian. The police arrived at the scene and an ambulance was called. The individual did not want to leave in the ambulance but was convinced to do so. The extent of their injuries are not known. The licensee stated the exposure device and associate equipment were not affected by the event. Texas Incident Number: 9979 |
| ENS 56289 | 29 December 2022 16:35:00 | The following information was provided by the Texas Department of State Health Services (the Agency) via email: On December 29, 2022, the Agency was notified by the licensee's consultant that a fire had occurred at the licensee's location. The fire was near two Vega America SHD gauges both containing 120 millicurie (original activity) cesium - 137 sources. The licensee has not been able to determine if the gauges were affected by the fire as of this report. There is a concern that the fire could reflash, so the licensee is being cautious about approaching the gauge. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No: 9977
On December 30, 2022, the licensee notified the Agency that they were able to inspect the gauges and neither gauge was affected by the fire. Notified R4DO (Gepford) and NMSS Events Notification via email |
| ENS 56100 | 9 September 2022 13:15:00 | The following information was provided by the Texas Department of State Health Services (The Agency) via email: On September 9, 2022, the Agency was notified by the licensee that on this day the shutter on a Vega SH-F1 gauge containing a 60 millicurie (original activity) cesium - 137 source failed to close during routine testing. Open is the normal operating position of this gauge. The licensee will contact the manufacture to repair the shutter. No individual received additional exposure due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9955 |
| ENS 56098 | 8 September 2022 19:08:00 | The following was submitted by the TX Department of State Health Services (the Agency): On September 8, 2022, the Agency was notified by the licensee that on this day, the shutter on a Vega SH-F2 gauge containing a 500 milliCuries (original activity) cesium - 137 source failed to close during routine testing. Open is the normal operating position of this gauge. The licensee will contact the manufacture to repair the shutter. No individual received additional exposure due to this event. TX event number I-9954 |
| ENS 56055 | 18 August 2022 22:02:00 | The following report was received via email from the Texas Department of State Health Services (the Agency): On August 18, 2022, at 0922 (CDT) hours, the Agency was notified of a source retrieval that occurred August 17th, 2022. The licensee stated the event occurred at a field location at 1245 (CDT) on August 17th, 2022. The licensee stated the location was at a facility located in Pampa, Texas. The licensee stated the event occurred when a piece of pipe fell onto the guide tube of a SPEC (Source Production and Equipment Company) - 150 exposure device and crimped the tube, preventing them from retracting the 60 Curie iridium (Ir-192) source. The licensee's retrieval individual was able to reshape the guide tube and the source was successfully retrieved by 1330 (CDT) that day. The exposure to the individual retrieving the source was 80 millirem. The associated equipment was removed from service and is undergoing inspection to ensure no other damage was done to the equipment. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9949 |
| ENS 55937 | 13 June 2022 17:48:00 | The following was reported by the Texas Department of State Health Services (the Agency) via email: On June 13, 2022, the licensee notified the Agency that on Friday, June 10, 2022, a truck containing a Insto Tek 3500 moisture density gauge was stolen. The gauge contained a 44 millicurie americium-241 source, and an 11 millicurie cesium-137 source. The licensee reported that the technician had stopped at a convenience store to buy some items and when they came back out the truck was missing. The licensee stated the gauge was locked in the back of the truck but was unsure if the keys to the locks were also taken. The licensee stated the gauge has an old (Global Positioning System) (GPS) tracking device that was inactive. The licensee stated they had contacted the GPS service company to see if the tracking device was still active and the gauge tracked that way. The licensee stated it would take up to 24 hours to determine if the tracking device could be used. The licensee stated the local police was notified of the theft. The individual who contacted the Agency stated they had not interviewed the technician about the event so some of the information requested by the Agency was unknown. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9934
On June 13, 2022, the licensee notified the Agency that a pickup truck with a Instro Tek 3500 moisture/density gauge had been stolen on June 10, 2022, when the technician left the truck running with the doors locked. The secured gauge in the back of the truck contained a 10 millicurie cesium-137 source and a 40 millicurie americium-241/beryllium source. The truck was recovered and was partially stripped for parts. The gauge was missing. The source was locked, however, the keys to the gauge were in the pickup truck. The licensee conducted training on security of the gauge and not leaving trucks running even if the gauge is properly secured. The company is purchasing GPS tracking units to install on the gauges. On Feb 21, 2023, the licensee reported to the Agency that the gauge was found on February 20, 2023, in the back of a stolen U-Haul truck. The licensee has the gauge in their possession and the gauge is in good condition. Notified R4DO (Roldan-Otero), NMSS Events Notification, and ILTAB via 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 |
| ENS 55886 | 6 May 2022 17:08:00 | The following information was provided by the Texas Department of State Health Services (the Agency) via email: On May 6, 2022, the Agency was notified by the licensee's Radiation Safety Officer (RSO) that they had discovered that multiple medical events had occurred at their facility. The licensee had discovered on Tuesday, May 3, 2022, the needle used on a high dose rate unit (HDR) was shorter than what they thought. This resulted in underdoses to the intended tissue. The licensee has identified three cases that resulted in underdoses of 92 percent, 95 percent, and 67 percent for a single fraction on three patients. The three events occurred between November 2020, and February 2021. The RSO stated they were notifying the prescribing physicians and patients involved. They are continuing to review previous cases to determine if any additional patients were involved. The licensee will notify the appropriate individuals as the events are discovered. The RSO did not know how many patients may be involved. The source was an iridium-192 source and the activity would vary depending on the date the treatment occurred. The RSO stated that due to the needle being shorter than believed, other tissue may have been exposed to higher-than expected dose and in some events the source may have never entered the patient. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9931 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. |
| ENS 55759 | 1 March 2022 10:17:00 | The following information was provided by the Texas Department of State Health Services (the Agency) via email: March 1, 2022, the Agency was notified by the licensee's radiation safety officer (RSO) that the shutter on a Vega model SHLD-1 gauge was stuck in the closed position. The gauge contains a 100 millicurie (original activity) cesium - 137 source. The gauge was tested while it was on the side of a vessel and functioned normally. The gauge was removed from the vessel and during that process the shutter was damaged and will no longer open. The gauge has been placed in storage. The manufacturer was contacted, and repair parts have been ordered. The RSO stated no individual received any additional exposure due to the event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9919 |
| ENS 55755 | 24 February 2022 12:19:00 | The following information was provided by the Texas Department of State Health Services (Agency) via email: On February 23, 2022, the Agency was notified by the licensee's radiation safety officer (RSO) that one of his crews had a failure of a shutter device on a Thermo Fisher Model 5190 density gauge containing a 20 millicurie (original activity) cesium - 137 source. The RSO stated that the shutter is a lead sheet that slides in a channel in front of the source. The RSO stated that the channel the sheet of lead slides through was damaged and the lead sheet will not stay in place if the gauge is moved (jiggled). It cannot be locked in the shield (closed) position. The workers removed the gauge and the pipe it was installed on and placed them both in storage. The RSO stated they were going to contact the manufacturer to have the gauge repaired. No individual received any significant exposure from this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: 9918 |
| ENS 55743 | 16 February 2022 20:26:00 | The following information was provided by the Texas Department of State Health Services (the Agency) by email: On February 16, 2022, the Agency was notified by the licensee's radiation safety officer (RSO) that one of his crews (at a temporary job site in Baytown, TX) were unable to retract an 89 Curie iridium - 192 source back into a QSA 880D exposure device. The radiographers were performing radiography when a pipe fell on the guide tube crimping it to the point that the source assemble could not pass through it. The radiographers isolated the area and contacted the company's RSO. A retrieval team went to the location and was able to recover the source within the hour of the start of the event. No member of the public received an exposure from the event. The radiographers did not exceed any exposure limits. The radiographer's dosimetry will be sent for processing. Texas Incident #: 9914 |
| ENS 55726 | 3 February 2022 11:04:00 | The following was received from the state of Texas (the Agency) via email: On February 3, 2022, the Agency was contacted by the licensee's service company and notified that while removing a Vega SH-F1B nuclear gauge from its mounted position it was dropped about 2 feet and the operating arm for the shutter was bent. The shutter was locked in the closed position and remained closed. The gauge contains a 20 millicurie (original activity) cesium - 137 source. Dose rates taken on the gauge housing after the gauge was dropped were normal. A leak test was performed on the source and the results were satisfactory. The gauge was placed in storage. The manufacturer is being contacted to repair the gauge. No overexposures occurred due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident # I-9909 |
| ENS 55776 | 9 March 2022 07:05:00 | The following information was received from the Texas Department of State Health Services (the Agency) via E-mail: On January 26, 2022, the Agency was contacted by the licensee to report they had received an exposure report from its dosimetry processor and one of its employees had received 59.052 rem for December 2021. The licensee believes the exposure is to the badge only. The individual performed duties involving the preparation of iodine-131 therapy pills. The individual involved with the exposure had never received an exposure anywhere near this high in the past. The licensee reported the individual was involved in a spill during the preparation of a pill and the licensee believes the badge became contaminated during the spill cleanup. The licensee stated they do not survey the dosimetry prior to sending them to their processor. The license stated the employee wore the badge from December 5, 2021 until December 16, 2021 when they left employment at the licensee's facility. The Agency requested additional information on the event. On March 8, 2022, the Agency received the responses to the Agency's request from the licensee. In the response the licensee stated that the spill did restrict access to the area for more than 24 hours. The licensee stated its investigation determined the exposure recorded on the badge was a result of the badge becoming contaminated during the spill cleanup. The licensee also stated the dose assigned to the individual was 1.385 rem based on previous months exposures. The licensee stated the individual's workload had not changed compared to previous months. Additional information has been requested by the Agency. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9911 |
| ENS 55481 | 17 September 2021 22:14:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On September 17, 2021, the Agency was notified by the licensee that a Troxler 3411 moisture density gauge containing a 40 milliCurie americium - 241 source and an 8 milliCurie cesium - 137 source was damaged at a temporary job site. The licensee reported that while the gauge was sitting on the ground and not being used it was run over by a bulldozer, snapping the operating arm of the cesium source. The source was in the shielded position when the event occurred and a radiation survey of the gauge after the event verified it was still fully shielded. The licensee stated the gauge would be returned to its storage location and arrangements would be made to have the gauge disposed of. No individual received an exposure that exceeded any limit. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: 9885
The following information was received via e-mail: Received pictures of the gauge. Pictures show the rod for the cesium source was bent. The dose rate meter appears to be reading 0.8 millirem per hour. Notified R4DO (YOUNG) and NMSS Events Notification group. |
| ENS 55414 | 18 August 2021 11:21:00 | The following information was received from the state of Texas (the Agency) via email: On August 18, 2021, the Agency was notified by the licensee that a Troxler model 3430 moisture density gauge was stolen from the back of an employee's truck. The employee's truck was parked at their apartment overnight. The licensee stated that the apartment complex security camera system showed the theft occurred at about 0149 CDT on August 18, 2021. The gauge contains a 40 milliCurie Americium - 241 source and an 8 milliCurie Cesium - 137 source. The licensee stated the gauge was locked using chains in the back of the pickup truck. The licensee reported local law enforcement has been notified of the theft. The Agency requested additional information from the licensee. Additional information will be provided in accordance with SA-300. TX Incident #: 9877 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 |
| ENS 55341 | 7 July 2021 09:50:00 | The following report was received from the Texas Department of State Health Services (the Agency) via email: On July 6, 2021, the Agency was contacted by the licensee's radiation safety officer (RSO). The RSO stated that a (former) employee had taken a Troxler moisture density gauge and did not return it. The gauge contains a 40 milliCurie americium - 241 source and an 8 milliCurie cesium - 137 source. The gauge was taken after the employee's employment had been terminated. The Agency attempted to contact the individual by phone twice, but they did not answer and they did not have voice mail to leave a message. At 2237 (CDT) on July 6, 2021, the Agency was notified by the RSO that the gauge had been recovered. The Agency has requested additional information from the licensee. At this time there is no reason to believe any individual would have been exposed. The report is made for informational purposes. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9865 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 |
| ENS 55283 | 30 May 2021 14:39:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On May 30, 2021, the Agency was notified by the licensee's radiation safety officer (RSO) that a Humboldt model 5001 EZ was stolen from a truck parked overnight at a technician's home. The gauge contains a 40 millicurie americium - 241 source and an 10 millicurie cesium - 137 source. The technician had taken the gauge home on May 29, 2021. The gauge was locked in the truck with two independent chains and locks. The technician went to their truck at 0900 (CDT) on May 30, 2021 and found both were cut and the transport case and the gauge were stolen. The RSO stated the operating arm was locked in the shielded position. The RSO stated the technician drove around in the immediate area in an attempt to find the gauge. The RSO stated local law enforcement had been notified. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9852
On November 10, 2021, the Agency was notified by the licensee that they had recovered the missing gauge on November 2, 2021. The licensee confirmed that the gauge cesium operating rod was locked in the shielded position. The licensee agreed to submit a written report to the Agency providing additional information. Notified R4DO (Gaddy), Mexico CNSNS, ILTAB and NMSS Event Notifications via 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 |
| ENS 55278 | 27 May 2021 09:41:00 | The following was received from the Texas Department of State Health Services (the Agency) by email: On May 26,2021, the Agency was notified by the licensee service provider that the shutters on two nuclear gauges were found stuck in the open position. Open is the normal operating position. The gauges are Vega model SH-F1 each containing a 20 milliCurie cesium-137 sources. The licensee stated there is no increased risk of exposure to members of the general public or workers at the facility due to the event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: 9850 |
| ENS 55255 | 12 May 2021 16:45:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On May 12, 2021, the Agency was notified by the licensee that a medical event had occurred on May 10, 2021. The event involved a prostate seed treatment using cesium - 131 seeds. The licensee reported that after the implant procedure they discovered that a large portion of the seeds had been implanted in the wrong location. The licensee stated the seeds that were misplaced ended up in mostly fatty tissue and they do not believe any adverse effects will be experienced by the patient. The licensee could not provide specific information on what percent of the prescribe dose had been received by the targeted tissue. The event and its cause is currently under investigation by the licensee. The prescribing physician has been made aware of the event and is notifying the patient. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9848 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. |
| ENS 55234 | 5 May 2021 11:35:00 | The following was received from the Texas Department of State Health Services (the Agency) by email: On May 5, 2021, the Agency was notified by the licensee that while performing fracking operations at a well site, the shutter operating arm roll pin fell out of a Berthold model 8010 nuclear gauge. The gauge contains a 20 milliCurie cesium - 137 source. The licensee was able to close the shutter. The licensee stated that the gauge roll pin had previously failed in November of 2020 (EN 54992). The licensee stated they had been experiencing problems with the gauge roll pins after changing the position of the gauge during operation making it closer to the pump and exposing it to greater vibration. This was the fourth event reported by the licensee since November 2020. The licensee stated that they have begun changing the location of the gauge by moving it further from the pump and therefore exposing it to less vibration. The licensee stated that they had discussed the current location with the manufacturer and was told by the manufacturer that the gauge should not be affected. The roll pin is 5/32 inches in diameter and is friction fitted into the operating rod and held in place by friction. No exposures occurred due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: I-9846 |
| ENS 55168 | 2 April 2021 08:45:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On April 1, 2021, at 1647 CDT, the Agency was notified by the licensee's radiation safety officer (RSO) that a Troxler model 3440 moisture density gauge containing an eight millicurie cesium-137 source and a 40 millicurie americium-241 source had been run over at a field site by a piece of equipment. The RSO stated the technician using the gauge stated that the cesium-137 source was in the fully shielded position when the event occurred. The RSO stated the technician was moving his equipment to a new test location at the site when the gauge was damaged. The RSO stated the gauge case was shattered and he was not sure how they would recover the gauge. He stated the gauge was reading 40 millirem per hour on contact near the cesium source. The RSO stated a barrier was establish around the gauge and the dose rate readings at the barrier were at background. The Agency advised the RSO to contact the manufacturer and request assistance in recovering the gauge. The RSO contacted the Agency a short time later and reported the manufacturer could not assist in the recovery. The RSO also stated that during his inspection of the gauge they discovered the cesium source was not in the fully shielded position. Also, it appeared that the source rod was no longer attached to the gauge housing. The RSO stated the source rod was bent so they could not retract the source into the shield. The licensee decided to recover the source by picking the source rod up from the end opposite of the source using channel locks and placing it in a thirty gallon can half full with sand and then covering the source with sand. The RSO reported the highest dose rate on the container after placing the source in the can and covering it with sand was 0.8 millirem per hour. The RSO contacted the Agency at 1828 CDT on April 1, 2021, and reported that the source was locked in their storage facility. The RSO stated they would work with the manufacturer to dispose of the gauge and sources. The RSO stated the gauge would be leak tested on April 2, 2021. The RSO stated the americium-241 source was not affected by the event. No individual received a significant exposure from the event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9835 |
| ENS 55151 | 23 March 2021 14:18:00 | The following was received from the state of Texas (The Agency) via email: On March 23, 2021, the Agency was notified by the licensee's radiation safety officer (RSO) that while conducting routine inspections the shutter on a Berthold LB 7440 nuclear gauge could not be closed. Open is the normal operating position. The gauge contains a 500 millicurie (original activity) cesium-137 source. The RSO stated the gauge is not an exposure risk to any individuals. The RSO stated the gauge manufacturer has been contacted and they are making arrangements to repair the gauge. The gauge is located on a barge currently working in the Intercoastal Waterway near Brownsville, Texas. Additional information will be provided as it is received in accordance with SA-300. Texas Event Number: 9833 |
| ENS 55150 | 23 March 2021 07:38:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On March 22, 2021, the Agency was notified by the licensee's radiation safety officer (RSO) that earlier that day the shutter on a Berthold LD 8010 containing a 20 millicurie cesium-137 (original activity) source had failed to close. The gauge is installed on an inline section of pipe used in well fracking. The RSO stated that the roll pin for the shutter had failed and the operating arm would not rotate the shutter. The gauge was removed from the pipe and the operator was able to close the shutter. The RSO stated no overexposures occurred due to the event. The RSO stated a radiation survey of the gauge indicated dose rates were normal. The gauge was secured in a trailer on-site. The RSO stated the manufacturer was contacted and gauge will be packaged in a type 'A' container and sent to the manufacturer for repair. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9832 |
| ENS 55051 | 30 December 2020 12:57:00 | The following information was received from the Texas Department of State Health Services (the Agency) via email: On December 30, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that a medical event had occurred at their facility. A patient was to receive a single fraction of 700 centigray from a high dose rate remote afterloader unit (HDR) but received a dose of 525 centigray. The patient was notified of the error and the RSO stated they were in the process of notifying the physician. The RSO stated that there would be no adverse effects to the patient from the error. The RSO was unsure of the manufacturer and model of the HDR unit and the activity of the iridium source that was used. Additional information was requested by the Agency. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: 9819 |
| ENS 55033 | 12 December 2020 17:06:00 | The following report was received from the Texas Department of State Health Services (the Agency) via email: On December 12, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that on December 11, 2020, they were unable to retract a source string composed of 16 strontium - 90 sources with a total activity of 36 milliCuries to the fully shielded position. The RSO stated they had completed the treatment of a patient using a Best Vascular model A1000 brachytherapy device and Novoste Beta-Cath Delivery System and when they attempted to retract the source to the shielded position, the source stuck just outside the device. The source did retract outside the patient. The source and associated equipment were placed in a shield box and have been placed in storage. The RSO stated neither the patient or individuals operating the device received any additional exposure from the event. The RSO stated the patient received the prescribed dose from the treatment. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9816 |
| ENS 55025 | 9 December 2020 09:21:00 | The following information was received from the Texas Department of State Health Services (the Agency) via email: On December 8, 2020, the Agency received an e-mail from the licensee stating that during routine testing the shutters on two nuclear gauges were found stuck in the open position. The gauges are Vega model SH-F1 both containing 20 milliCuries (original activity) cesium-137 sources. The licensee reported there is no risk of radiation exposure to members of the general public or workers at the facility due to the failures. The licensee stated they were working on a plan to repair the gauges and would provide that information once the plan is completed. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No: I-9815 |
| ENS 54992 | 11 November 2020 12:00:00 | The following was received from the Texas Department of State Health Services (the Agency) by email: On November 11, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that on November 10, 2020, while working at a field site, the shutter roll pin on a Berthold Technologies LB 8010 nuclear gauge fell out and the shutter vibrated closed. The gauge contains a 20 milliCurie (original activity) source. The gauge is installed on a pipe which is installed in line with existing piping at the well site for testing. The gauge was taken out of service and the RSO stated they would repair the gauge within the next few days. The RSO stated the gauge does not pose an exposure risk to any individual. Additional information will be provided as it is received in accordance with SA- 300. Texas Incident No.: I-9811 |
| ENS 54937 | 8 October 2020 12:44:00 | The following information was received from the Texas Department of State Health Services (the Agency) via email: On October 8, 2020, the Agency was contacted by the licensee and notified that while being used at a job site, a Troxler 3440 nuclear gauge was damaged by a road grader. The gauge contains a 40 milliCurie americium-241 source and an 8 milliCurie cesium-137 source. The licensee's technician had started a measurement and walked back to their truck when the grader came around a dirt pile and struck the gauge before the technician could respond. The cesium source operating rod was extended about 6 inches into the soil. The licensee performed a survey at the gauge and the reading at 3 feet was 1.2 millirem per hour. The licensee established a boundary at 15 feet from the gauge. The radiation safety officer (RSO) responded to the location. The RSO inspected the gauge and thought they could retract the cesium source back to the shielded position. The RSO's attempt to retract the source was successful. The RSO took a radiation reading 3 feet from the source and it was 0.14 millirem per hour. The gauge was placed in the transport case and will be taken to the licensee's storage area. The RSO stated they would contact the manufacturer to dispose of the gauge. No individual received an exposure due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I - 9805 |