Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 56973 | 16 February 2024 18:10:00 | The following information was provided by Texas Department of State Health Services (the Department) via email: On February 16, 2024, the Department was contacted by the licensee's radiation safety officer (RSO) that the source in a Mark 1 irradiator could not be raised or lowered. The device contains a 10,000-curie cesium-137 source (original activity manufactured 6/25/1986). The source problem was discovered when a researcher was attempting to irradiate a few mice and the source would not raise. The RSO stated they inspected the device and found a fuse that controlled the source's movement both up and down had failed. The RSO stated they had contacted a service company to repair the device. The source is in the fully shielded position. No individuals received any exposure due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas NMED number: TX240006 |
| ENS 56917 | 9 January 2024 17:10:00 | The following information was provided by the Texas Department of State Health Services (the Department) via email: On January 9, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that during routine checks, the shutters on three Vega America SH-F2 source holder failed to close. Open is the normal operating position for the gauges. Each gauge contains a 200 millicurie cesium-137 source. The gauges do not create an exposure risk to any individual. The RSO stated they have contacted a service provider for repairs to the gauges. Additional information will be provided as it is received in accordance with SA300. Texas Incident Number: I-10076 NMED Number: TX240001 |
| ENS 56621 | 12 July 2023 19:25:00 | The following information was received from the Texas Department of State Health Services (the Agency) via email: On July 12, 2023, the Agency was notified by the licensee's service company that during routine shutter checks, the shutter on a Vega Americas model SH-F2 (gauge) could not be shut. The gauge contains a 200 millicurie (original activity) Cs-137 source. Open is the normal operating position for the shutter. The licensee has made plans to repair the gauge in the next seven days. The service company stated there is no risk of radiation exposure to members of the general public or radiation workers due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 10036 |
| ENS 56597 | 29 June 2023 14:18:00 | The following was provided by the Texas Department of State Health Services (the Agency): On June 29, 2023, the Agency was notified by the licensee's radiation safety officer (RSO) that a source disconnect had occurred on June 28, 2023, at a temporary job site. The device (camera) was a SPEC 150 exposure device containing a 43 curie Iridium-192 source. The radiographers had placed the exposure device on an I-beam 15-feet above the floor to shoot a pipe. The device was raised to the pipe using a person lift. After the last shoot, the radiographer removed the guide tube and placed the guide tube and camera in the person lift with them. The radiographer stated they had performed a survey as they approached the camera and said the reading was bouncing up and down. The radiographer stopped halfway up and verified the crank-out indicated that the source was retracted. The radiographer removed the camera and guide tube and lowered them to the floor. Both radiographers noted their self-reading dosimeters were off scale. The radiographers contacted the RSO who had them set up a 2 millirem boundary and a qualified individual then retrieved the source. The source and camera were returned to the licensee's storage location. The radiographers' badges were sent for processing. On June 29, 2023, the RSO reported both radiographers' badges read less than 100 millirem. Additional information has been requested and will be provided as it is received in accordance with SA-300. Texas Incident No.: 10031 Texas NMED No.: TX230029 |
| ENS 56498 | 2 May 2023 17:04:00 | The following information was received from the Texas Department of State Health Services (the Agency) via email: On May 2, 2023, the Agency was notified by the licensee that they were unable to locate a 200 millicurie cobalt - 60 source. The licensee stated that the company had three locations in the United States, one in California, one in Louisiana, and one in Texas. In January of 2023, the company decided to close its offices. The company transferred all its sources to the Texas location. The sources were then sent to a source disposal company in Texas. During the last transfer of sources, the cobalt source could not be found. The licensee searched for the source at the Texas facility but could not find it. The process of locating where the source might be is complicated by the fact that the licensee had laid off most of the employees. The Radiation Safety Officer (RSO) was included in the layoff. The individual tasked by the company to dispose of the sources contacted a few of the previous employees and was told that the source was transferred to the location in Louisiana. (The Agency) asked if they had the documents for the transfer. He stated they had given all the documents to the Louisiana location. He did not have a copy of the forms. He said the source itself is about half the size of a magic marker. He said it is normally stored in a lead box in a sea van. He said that they would search their paperwork including the sign-out log in Louisiana to see if they can confirm the source was there. The Agency advised the individual to go to Louisiana and search for the source in and around the storage area. He was also advised to get someone added to their license as RSO. Additional information will be provided as it is received in accordance with SA-300 Texas Incident Number: 10014 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 56396 | 9 March 2023 09:02:00 | The following information was provided by the Texas Department of State Health Services (the Agency) via email: On March 9, 2023, the Agency was notified by the licensee's radiation safety officer (RSO) that a Source Production and Engineering Company (SPEC) 150 exposure device containing a 121 curie iridium-192 source was stolen from one of the company's trucks. The radiography crew stated they left their job site to get some food at around midnight and stopped at a fast-food restaurant. They went into the restaurant to eat. The radiographers stated they failed to set the alarm on the dark room. They also stated they had left the key for the exposure device transport box in the dark room. The radiographers completed their meals and went back to the job site. When they went to get the exposure device they found it was missing. The radiographers contacted the RSO and a search was conducted for the device. It was not found. The RSO reviewed security footage at the location the radiographers were working and confirmed the exposure device was not on the tailgate of the truck. They reviewed security footage at the fast-food restaurant, but the cameras were not pointed in the right direction to see the truck. The RSO stated there is a restaurant across the street from where they believe the exposure device was stolen that has security cameras. They will go there when it opens to see if the theft was captured by their cameras. The RSO stated that personnel will be sent back to the area where they believe the theft occurred for additional searches. The RSO stated they have sent people out to contact local pawn shops and scrap dealers and notify them of the theft and provide their contact information. Local law enforcement have been notified of the event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident number: I-10000 Notified DHS SWO, FEMA Operations Center, CISA Central, USDA Operations Center, HHS Operations Center, DOE Operations Center, EPA Emergency Operations Center, FDA EOC (email), FEMA NWC (email), and NuclearSSA (email).
The following update was provided by the Texas Department of State Health Services (the Agency) via email: On March 9, 2023, at 1935 (EST), the Agency's radiation safety officer and an incident investigator arrived in the area where the exposure device was reported stolen. They searched the area using the Agency's (Radiation Solution Inc) (RSI) RS-700 mobile radiation monitoring system. They did not find the missing device or source. They intend to meet with the licensee's RSO this morning and search a broader area. Notified R4DO (Gepford), and NMSS Events Notification, ILTAB (MacDonald), IRMOC (Ulses), INES Coordinator (Smith), CNSNS (Mexico) via email.
The following update was provided by the Texas Department of State Health Services (the Agency) via email: The Agency personnel have completed their search in the Houston area and are returning to Austin. They did not locate the missing exposure device. The licensee will continue looking for the device. Notified R4DO (Gepford), and NMSS Events Notification, ILTAB (MacDonald), IRMOC (Ulses), INES Coordinator (Smith), CNSNS (Mexico) via email.
The following update was provided by the Texas Department of State Health Services (the Agency) via email: On March 15, 2023, the Agency conducted interviews with the licensee and individuals involved in the event. Using the licensee's GPS records, it was determined that the theft occurred between 2314 and 2355 CST the night of March 8, 2023. Notified R4DO (Kellar), and NMSS Events Notification, ILTAB (MacDonald), IRMOC (Crouch), INES Coordinator (Smith), CNSNS (Mexico) via email.
The following update was provided by the Texas Department of State Health Services (the Agency) via email: On May 23, 2023, the Agency received a phone call from an apartment manager in Houston, Texas. The manager stated that he was cleaning an apartment when he found the exposure device on the balcony of the apartment. The manager provided the serial number of the device which matched the number of the stolen device. The Agency contacted the licensee who drove to the location and recovered the device. The licensee reported that the source was still fully shielded and that dose rates on the device were normal. The Agency notified the Federal Bureau of Investigation (FBI) Special Agent who has been involved with this event that the device had been located and recovered. The licensee reported that it had been in phone contact with the FBI agent. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Vossmar), NMSS (Rivera), NMSS Events Notification (email), ILTAB (MacDonald), IRMOC (Grant), INES Coordinator (Smith), CNSNS (Mexico) via email, DHS SWO, FEMA Operations Center, CISA Central, USDA Operations Center, HHS Operations Center, DOE Operations Center, EPA Emergency Operations Center, FDA EOC (email), FEMA NWC (email), and Nuclear SSA (email). 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* |
| ENS 56379 | 22 February 2023 18:34:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On February 22, 2023, the Agency was notified by the licensee's service company that the shutter on a Vega SH-F2B was found stuck in the open position during routine testing. Open is the normal operating position. The gauge contains a 200 millicurie (original activity) cesium-137 source. The gauge does not present an exposure risk to members of the general public or plant workers. The manufacturer has been contacted to conduct the repairs to the gauge. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9992 |
| ENS 56377 | 21 February 2023 21:35:00 | The following information was provided by the Texas Department of State Health Services (the Group) via email: On February 21, 2023, the Group was notified by the licensee's radiation safety officer (RSO) that a cobalt-60 source was stuck in the unshielded position. The source is used in a teletherapy unit for non-human experimental irradiation. The source is pointed towards the floor. The RSO stated they contacted their service company and was told it is probably caused by low air pressure as air pressure is used to drive the source. The RSO stated the source/unit was located in the basement of the facility. The RSO stated they performed radiation surveys in adjoining rooms and the room above where the exposed source is located, and all dose rates were normal (less than 200 microrem/hr). The service provider will be at the licensee's location on February 23, 2023, to inspect the unit. The access door has been locked and 'Caution' tape has been placed on the door jam. No over exposures have occurred due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9991
The following update was received from Texas Department of State Health Services (the Agency) via email: On February 22, 2023, the licensee's RSO notified the Agency that they had just talked with the service company that would retrieve the source and discussed the operation. The job is expected to start at 0830 CST on February 23, 2023. The RSO stated the individual will enter the room wearing a Personal Radiation Dosimeter (PRD), an OSL (Optically Stimulated Luminescence) dosimeter, and an Instadose for exposure monitoring. Alarms will be set on the PRD. The RSO stated they will have a pre-job safety briefing before the technician enters the room and will establish turnback values for the job. The technician will enter the room and rotate the source head to point the source away from them. They will then force the source back into the shield. The service company estimates the technician will receive 500 millirem for the job. The RSO stated the room has video surveillance and will also have audio capabilities. The RSO stated the job is anticipated to take less than 15 minutes. The RSO will notify the Agency when the technician enters the room for the first time and leaves the room when the job is completed. The Agency has requested additional information.
The following update was received from Texas Department of State Health Services (the Agency) via email: On February 23, 2023, the licensee notified the Agency that the service company was able to return the source to the fully shielded position by manipulating the systems air pressure. No individual received any significant radiation exposure from the operation. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Roldan-Otero) and NMSS Events Notification via email.
The licensee's radiation safety officer provided the following additional information: `(The teletherapy unit that had a stuck source) is a Theratron 780C, and it was the Numatics Mark 8 solenoid valve that failed.' Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Vossmar) and NMSS Events Notification via email. |
| ENS 56314 | 18 January 2023 16:37:00 | The following report was received via email from the Texas Department of State Services (the Agency): On January 18, 2023, the Agency was notified by the licensee that one of its radiography crews (working in Midland, TX) was unable to retract a 99.0 curie iridium - 192 (Ir-192) source into the fully retracted and locked position in a QSA 880D exposure device. The licensee stated they were able to retract the source into the exposure device, but it would not lock in the fully retracted position. An individual on the license approved to recover sources went to the site to retract the source. The licensee contacted the manufacturer who was able to provide instructions to the field team on how to return the source to the locked position. The licensee reported no overexposure occurred due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No: I-9981 Texas NMED No.: TX230002 |
| ENS 56271 | 14 December 2022 15:23:00 | The following information was provided by the Texas Department of Health Services (the Agency) via email: On December 14, 2022, the Agency was notified by the licensee's radiation safety officer (RSO) of a potential overexposure event. The RSO reported three of their radiographers were working at a remote site using a 30.4 curie cobalt 60 source. The exposure time for each exposure was two minutes. The distance from the source to the pipe was two feet. During the first exposure, one of the radiographers was between the source and the pipe being tested. The RSO stated the individual stayed in the area for about one minute. The radiographer operating the source was standing behind a brick wall and was unaware of the individual being in the area. The operator thought the others had cleared the area, and it was safe to perform the exposure. The individual who received the exposures stated the noise in the area was too loud to hear their alarming rate meter. The exposed individual's self-reading dosimeter was off scale. All radiographers' dosimeters have been sent to the licensee's dosimetry processor for reading. The RSO stated their calculations indicated the individual could have received 7 rem from this event. The RSO stated the individual exposed had received 12 millirem prior to this event. All three individuals have been removed from any duties that would require any additional exposure. Additional information will be provided as it is received in accordance with SA-300. Texas Incident no.: 9973 Texas NMED no.: TX220041
On December 16, 2022, the licensee reported they had received the badge reading for the individual involved in this event. The Deep Dose Equivalent (DDE) on the badge was 5,450 millirem bringing the individuals DDE total for the year to 5,662 millirem. The Agency has requested the licensee determine if the badge was worn in the highest dose field during the event. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Drake) and NMSS Events Notification via email. |
| ENS 56248 | 30 November 2022 17:19:00 | The following information was provided by the Texas Department of State Health Services (the Agency) via email: On November 30, 2022, the Agency was notified by the licensee's radiation safety officer (RSO) that during routine testing the shutter on a Berthold model LB7440 nuclear gauge the shutter failed to close. The gauge shutter is in the open position, which is the normal operating position. The gauge contains a 30 millicurie Cesium - 137 source. The RSO stated the roll pin on the shutter operating arm had broken. The manufacturer has been contacted to repair the gauge. The RSO stated dose rates around the gauge were normal. No individual received any additional exposure as a result of this event. The gauge does not pose an exposure risk. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9968 |
| ENS 56107 | 14 September 2022 17:02:00 | The following information was provided by the Texas Department of State Health Services (Agency) via email: On September 14, 2022, the Agency was notified by the licensee that the shutter on a Thermo Fisher Scientific model 5208 gauge had failed to close during routine testing. The gauge contains a 1,000 milliCurie cesium - 137 source. Open is the normal operating position for the gauge shutter. The failure does not present an exposure risk to any individual. The licensee is unsure if they will have the gauge repaired or replaced. Additional information will be provided in accordance with SA-300. Texas Incident Number: I-9958 |
| ENS 55880 | 5 May 2022 08:14:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On May 4, 2022, the licensee's radiation safety officer contacted the Agency and reported one of it's Humboldt 5001EZ gauges containing an 8 millicurie cs-137 source and a 40 mCi am-241 source had been struck by a bulldozer at a temporary field site. The gauge was damaged, and the licensee stated their engineer was going to the site to inspect and recover the gauge. The RSO contacted the Agency later that day and stated the source was in the shielded position and readings on contact with the transport case was 5 millirem an hour and 2 millirem an hour at three feet. The licensee transported the gauge back to it's facility. The licensee contacted it's service provider who will dispose of the gauge. No significant exposures were received as a result of this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number I-9930 |
| ENS 55680 | 30 December 2021 14:37:00 | The state of Texas (the Agency) reported the following via phone and email: On December 30, 2021, the Agency was notified by the licensee that on December 29, 2021, one of its technicians was unable to fully retract a 10 millicurie cesium-137 source to its fully shielded position. The source is installed in a Humboldt 5001EZ moisture density gauge. The technician had performed 3 samples that morning and the failure came at the end of the (fourth) exposure. The technician placed the gauge into its transport container and returned the gauge to the shop. The radiation safety officer (RSO) performed a survey of the gauge and found the highest reading 1 meter from the gauge was 0.4 millirem per hour. The RSO stated the transport index for the gauge measured that morning was 0.2. The RSO stated that the source was stuck about 2 inches outside from the fully shielded (position). The RSO stated they used a hammer and anchor bolt and drove the source back into the shielded position. The RSO stated they noticed wet clay material oozing out of the area between the source shaft and the gauge case. The RSO believes the clay is what was preventing the source from fully retracting. The RSO stated they were taking a leak test of the cesium source. The RSO was instructed to isolate the hammer and bolt used to drive the source to the shielded position. The Agency went to the licensee's location and performed fixed and removable contamination survey on the hammer and anchor bolt used to drive the source back to the shielded position. No contamination was detected. The RSO's hands and clothing was surveyed for contamination. No contamination was detected. The RSO stated the gauge will be sent to the service company after the results of the leak test are received. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9905 |
| ENS 55327 | 25 June 2021 13:47:00 | The following information was received via E-mail: On June 25, 2021, the Agency (Texas Department of State Health Services) was notified by the licensee's Radiation Safety Officer (RSO) that while conducting radiography in their shooting bay, they experienced a source disconnect. The disconnect involved a QSA 880D exposure device containing a 60 curie iridium-192 source. The RSO stated the radiographer had completed an exposure and was entering the bay to exchange the film. As they passed the entrance beam the radiation alarm went off. The radiographer exited the area. The licensee was unable to retract the source. They contacted a service company who came to the licensee's location. It was determined that the ball on the drive cable had broken free of the drive cable. The service company was able to retract the source into the exposure device. No overexposures occurred due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9860. |
| ENS 54984 | 5 November 2020 12:13:00 | The following is a summary of information received from the Texas Department of State Health Services (the Agency) via email: On November 5, 2020, the Agency was notified by the licensee that three of their nuclear density/level measurements gauges had been stolen from one of their storage sites. The storage site had been vandalized and various pieces of equipment were damaged as well. The licensee has contacted local law enforcement about this incident. The gauges contain Cs-137 sources. The total activity of the missing sources is estimated to not exceed 200 mCi. The licensee does not have any additional information regarding the incident or gauges at this time. Texas Incident Number: 9808
On November 9, 2020, the licensee provided additional information on the stolen gauges. All gauges contained cesium-137 sources. Two of the gauges were Thermo Fisher model 5192 gauges. One of the two gauges contained a 250 milliCurie (mCi) (original activity now 215 mCi) source and the other contained a 200 mCi (now 162 mCi) source. The third gauge was a Thermo Fisher model 5190 gauge containing a 200 mCi (now 166 mCi) source. The gauges had been stored in a locked cage on the licensee's site. The gauges were still installed on the pipes they were used on. The licensee stated the last time the gauges were seen was September 1, 2020. The Agency instructed the licensee to notify local scrap yards of the theft and provided them with a copy of the attached picture. The Agency has requested additional information from the licensee. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Dixon), ILTAB (email), NMSS Events Notification (email), and CNSNS-Mexico (email)
On December 6, 2020 at 2033 (CST) hours the Agency was notified by the licensee that the three devices reported stolen in this event have been recovered. The gauges are in the possession of the licensee and are locked inside a secured location. Additional information will be provided through NMED as it is received.. Notified R4DO (Gepford), ILTAB (email), NMSS Events Notification (email), and CNSNS-Mexico (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 54891 | 9 September 2020 11:26:00 | The following was received from Texas Department of Health Services (the agency) via email: On September 9, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that on September 8, 2020, one of his crews lost a QSA 880D exposure device containing a 38.1 Curie iridium-192 source. The radiography crew had placed the exposure device on the tailgate of their truck at the licensee's location. The crew drove away from the site with the exposure device still on the tailgate. The device fell off the truck a short distance from the licensee's location. A second crew left the licensee's location a short time (10 minutes) later and found the device on the pavement. The second crew performed a radiation survey of the device and found the radiation levels to be normal and the source was still fully shielded. The second crew returned the device to the licensee's location. The device was inspected and did not appear to be damaged. The licensee has sent the device to the manufacturer for inspection. Additional information has been requested from the licensee. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9798 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 |
| ENS 54886 | 5 September 2020 14:35:00 | The following was received from the Texas Department of State Health Services (the Agency) via email: On September 5, 2020, The Agency was notified by the licensee's site radiation safety officer (SRSO) that a Humboldt EZ 5001 moisture/density gauge was damaged at a temporary job site when a bulldozer struck the gauge. The gauge contains a 40 milliCurie americium-241 source and a 10 milliCurie cesium-137 source. The cesium source was in the shielded position when the event occurred. The operating rod was bent, and the SRSO stated he did not believe the cesium source rod would move. The SRSO stated they performed radiation surveys around the gauge and the highest reading they obtained was 1.3 millirem per hour, which is a normal reading. The SRSO stated they were taking the gauge back to their storage location and would perform a leak test of the gauge. The event did not present an exposure risk to any individual. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: 9795 |
| ENS 54862 | 27 August 2020 09:34:00 | EN Revision Imported Date : 9/2/2020 AGREEMENT STATE REPORT - UNABLE TO DETERMINE IF SOURCE IN SHIELDED POSITION ON LEVEL INDICATOR The following information was received via E-mail: On August 26, 2020, the Agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that while making preparations for the coming hurricane, the position of the source rod on a Tracerco, Model T-218-160032 (used for level indication) could not be confirmed. The source rod contains 10 cesium-137 sources of 10 milliCuries each (original activity.) The RSO stated when they return the sources to the shielded position, the control system does indicate the sources are shielded as indicated by a light change on the system console. When the licensee attempted to shield the sources on this day, the light did not change to indicate the sources were shielded. The gauge source rod is operated manually. They tried it a couple of times, but the light still did not change. A survey was performed on the outside of the vessel. The RSO stated there wasn't enough change in dose rate readings with shutter in the open and closed positions to determine whether the sources were shielded based on survey. The RSO stated it may be that the sources are not moving, or it may be that there is an issue within the control system causing the light not to change. They cannot determine at this time which problem is occurring. The RSO is contacting the manufacturer to send someone out after the hurricane. There is no risk of exposure. The RSO stated they will update the Agency once the manufacturer determines the problem. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9787
The following information was received via e-mail: On September 1, 2020, the licensee notified the Agency (Texas DSHS) that on August 31, 2020, a service company came onsite to investigate the shutter problem they had reported, and identified that there was no mechanical issue with the shutter. The problem they had was a failure of the output signal to indicate source position. The source rod was functioning normally. Based on this information, the Agency is retracting this event. Notified R4DO (Deese) and NMSS Events (email). |
| ENS 54851 | 21 August 2020 15:08:00 | EN Revision Imported Date : 9/14/2020 AGREEMENT STATE REPORT - NUCLEAR GAUGE ENGULFED DURING FIRE The following information was received from the Texas Department of State Health Services (the Agency) via email: On August 21, 2020, at 1307 CDT the Agency was notified by the licensee consultant (LC) that a fire was burning on one of its dredges off the coast Corpus Christi, Texas. The LC stated the drudge had a 250 milliCurie (original activity) (Cs-137) source in a Berthold model 7440 nuclear gauge installed on a pipe for density measurement. The LC did not have any other information on the location, but knew the dredge was in between 40 and 50 feet of water. The LC stated that the personnel on board were fighting the fire. The LC stated they believed that the gauge would be engulfed by the fire. The LC stated they would supply additional information once the fire is out and they have a chance to inspect the equipment. At 1553 CDT the LC contacted the Agency and stated the dredge workers were able to take dose rate reading about two feet from the gauge and the reading was 26 millirem per hour. The LC stated that the steel was still too hot to stay very long in the area. The LC stated (when asked) that they believe the fire is out. The LC stated the current priority on the drudge was locating several missing individuals. The LC stated they directed personnel on the drudge to take a contamination survey on the gauge as soon as possible. The LC stated the gauge source serial number was 0025-06. A search of news sources in Corpus Christi, Texas by the Agency found that a barge had struck an underwater natural gas line at a facility in Corpus Christy, Texas. This information was verified by the licensee's LC. The news reports stated the event occurred at about 0800 CDT. The report stated that the Texas Division of Emergency Management and Texas Department of Public Safety personnel are on the ground to provide support, and the Texas Commission on Environmental Quality is monitoring air quality in the area. The United States Coast Guard is assisting in the fire fighting and search for individuals. The name of the dredge involved was provided in several reports. The Agency contacted the LC verified the ship was owned by the licensee. This information was verified by the Agency by reviewing four different news sources. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9784
The following information was received from the Texas Department of State Health Services (the Agency) via email: On August 21, 2020, at 2200 CDT, the Agency was notified by the LC that the dredge has sunk. The dredge is believed to be in 45-50 feet of water on its starboard (stbd) side. The gauge is located on the stbd side of the vessel and the shutter was in the open position. The LC stated that after talking to the radiation safety officer who is at the location the LC stated the dose rate they were able to take earlier today and was reported as 26 mR/hr at 2 feet was 26 mR/hr at 6 feet. A request for the composition of the source material has been made to the manufacturer. The search for four missing persons continues and is the current priority. Notified R4DO (Taylor), NMSS (Jamerson), and NMSS Events Notifications (email).
The following information was received from the Texas Department of State Health Services (the Agency) via email: On August 22, 2020 the manufacturer confirmed the source involved in this event is made of ceramic source material and is double encapsulated. Follow-up phone call to the Agency confirmed that the fire is out and the LC and the RSO are working on a recovery plan. First priority remains the search for the four missing persons. Notified R4DO (Taylor), NMSS (Jamerson), and NMSS Events Notifications (email).
The following information was received from the Texas Department of State Health Services (the Agency) via email: The Agency has contacted the licensee's radiation safety officer (RSO) and received the following information. The RSO stated that before the vessel sank a hazmat crew was able to get eyes on the gauge. The hazmat team stated the gauge did not appear to have been damaged by the fire. The area around the gauge also did not appear to have been damaged by the fire. The RSO stated the current plan is to raise the vessel, survey the gauge, and close the shutter. The RSO stated they would send a written report providing additional information. Notified R4DO (Taylor), NMSS (Jamerson), and NMSS Events Notifications (email).
The following information was received from the Texas Department of State Health Services (the Agency) via email: The Agency contacted the licensee's consultant (LC) on August 24, 2020, and requested an update on the event. The consultant stated he had received a written report completed by the licensee's RSO for his review. The LC stated he is on vacation but hoped to forward it to the Agency today. As of the writing of this update the report has not been received by the Agency. The LC stated they had a contractor in place to retrieve the vessel. Once raised the plan is to inspect the gauge, perform surveys of the gauge, and close the shutter. The raising of the vessel is not scheduled to take place until next week or the week after that due to difficulties getting the needed equipment in place. In addition, the local weather may hamper recovery activities. Notified R4DO (Kellar) and NMSS Events Notifications (email).
The following information was received from the Texas Department of State Health Services (the Agency) via email: On August 25, 2020, the Agency received the following information from the licensee's radiation safety officer: 'We do not have the equipment to do a deep-water survey of the radiation source. T&T our salvage contractor is ordering the equipment to do the survey of the source to insure the safety of their divers because the source has not had an up-close survey since the vessel sunk. We have taken a survey above the water and have not picked up any radioactivity.' The report from the licensee has been delayed while a review is completed. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Kellar) and NMSS Events Notifications (email).
The following information was received from the Texas Department of State Health Services via email: The licensee has confirmed that a member of a hazmat team who was able to inspect the gauge from a small boat next to the vessel prior to it sinking stated the gauge appeared undamaged, the wires leading to and from the gauge appeared to be undamaged, and that painted surfaces in the area of the gauge did not appear to be damaged by heat or the fire. The licensee stated they were unable to locate any pictures of the gauge prior to the vessel sinking. The licensee stated that their salvage contractor is ordering the equipment to do an underwater survey of the source to insure the safety of their divers because the source has not had an up-close survey since the vessel sunk. The licensee stated they have taken a survey in the water above the vessel and have not picked up any radioactivity. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Kellar) and NMSS Events Notifications (email).
The following information was received from the Texas Department of State Health Services (the Agency) via email: On September 11, 2020, the licensee reported the dredge was raised to the surface and the gauge was recovered on the dredge. The gauge was undamaged, and the licensee was able to shutter the source. Dose rates at the gauge were reported as normal. The shutter has been locked closed and the source will be disposed by a contractor. Additional information will be provided via the Nuclear Materials Events Database. Notified R4DO (Warnick) and NMSS Events Notifications (email). |
| ENS 54815 | 4 August 2020 21:21:00 | The following information was received from the Texas Department of State Health Services (the Agency) via email: On August 4, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that an event occurred during the administration of Y-90 TheraSpheres on August 3, 2020. The RSO stated the written directive prescribed dosage was 22.3 mCi. During the administration of the TheraSpheres, the pressure observed by the Authorized User (AU) became significantly less than expected, and activity leaving the dose administration vial into the catheter decreased significantly before the entire dose could be delivered. The RSO stated a TheraSpheres (Boston Scientific) representative was present during the procedure and assisted the authorized user through troubleshooting, and remote consultation with TheraSpheres medical specialists. However, flow from the dose administration vial could not be re-initiated. The AU chose to end the procedure. Following survey of the dose administration vial in the hot lab, it was determined that approximately 7.1 mCi (31.8 percent) was delivered to the patient. The RSO stated that their initial assessment is that this was the result of a device malfunction. There were no adverse effects to the patient. It is likely that a second procedure will be scheduled to complete the procedure. The RSO stated that the patient and referring physician were notified. This is the first event involving TheraSpheres reported to the Agency by this licensee. The RSO stated additional information on the event will be provided within the next 10 days. Additional information will be provided as it is received by the Agency in accordance with SA-300. Texas Incident Number: 9782 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 54805 | 30 July 2020 08:13:00 | The following information was received via email: On July 29, 2020, the Agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that during the performance of routine gauge inspections two gauges were found to have shutters that would not function. One was a Ronan model SA-1-F37 gauge containing a 150 mCi cesium-137 source with the shutter stuck in the open position. The second gauge was a Ronan model SA-1-C10 gauge containing a 100 mCi cesium-137 source with the shutter stuck in the closed position. Both source activities reported are the original activities. The gauge shutters are stuck in the normal operating position and do not create any additional exposure risk to any individual. The licensee has contacted a service company to repair the gauges. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9780 |
| ENS 54521 | 11 February 2020 22:30:00 | The following information was received from the state of Texas via email: On February 11, 2020, the Agency (Texas Department of State Health Services) was notified of an event by the licensee's consultant. The consultant stated the licensee had purchased a QSA 880 exposure device containing a 111 Curie iridium - 192 source from a licensee in Houston, Texas. The licensee's Radiation Safety Officer (RSO) picked up the shipment at the common carrier shipping building in Amarillo, Texas and placed (it) in the back of his pickup truck. The RSO then surveyed the package. The RSO found readings of 40 millirem per hour (mR/hr) on three sides, but 400 mR/hr of the fourth side. The RSO confirmed the reading with a second meter. The RSO contacted the consultant and the consultant had the RSO tape a self-reading dosimeter (SRD) to the side of the box with the highest reading and leave it there for 10 minutes. After ten minutes the RSO read the SRD and found it reading 50 millirem. The RSO contacted the company manager (CM) in Dumas, Texas. The CM brought two additional meters to the common carrier location. New readings were taken and the highest dose rate was now 700 mR/hr. The RSO moved the truck to a remote area at the common carrier facility and placed barriers up. The consultant stated they have contacted the licensee who shipped the device who has provided pictures on how the device was packed for shipment. The RSO is qualified for source retrieval. It was decided that they would get a power screw driver (to minimize time in the area) and remove the top of the box and inspect the exposure device. At 2116 CST, the Agency was notified by the licensee that they had open the transportation container and inspected the device. The RSO found that both the shutter and cap were opened. The RSO closed the shutter and cap using a remote handling tool. A dose rate taken after closing the shutter and cap was 40 mR/hr. The licensee is transporting the device to its storage location. The licensee was instructed to provide dose estimates for any individual who may have been exposed. Additional information will be provided as it is received in accordance with SA300. Exposure received from closure of the door and cap was approximately 3 millirem. Texas Incident Number: 9742 |
| ENS 54326 | 11 October 2019 16:35:00 | The following information was receive from the Texas Department of State Health Services (the Agency) vial e-mail: On October 11, 2019, the Agency was notified by the licensee's radiation safety officer (RSO) that the shutter on a Vega Americas SHLG-2 source holder containing a 5,000 milliCurie cesium-137 source was stuck in the open position. The stuck shutter was found during a routine check of the gauge. Open is the normal operating position. The RSO stated the gauge does not pose an exposure risk to any individual. The RSO stated a service company has been contacted to look at the gauge. The RSO stated they have not determined if they will repair or replace the gauge. Additional information will be provided as it is received in accordance with SA 300. Texas Incident No.: I-9720 |
| ENS 54327 | 11 October 2019 18:29:00 | The following information was received from the Texas Department of State Health Services (the Agency) via E-mail: On October 11, 2019, the Agency was contacted by the licensee's radiation safety officer (RSO) who reported a medical event had occurred at their facility. The RSO stated that the event involved a patient who was to receive a treatment with yttrium-90 microspheres. The administering physician had difficulties setting up the injection apparatus and installed an additional piece of tubing in-line with the injection tubing. Because of the additional length of tubing, the patient received only five percent of the prescribed activity. The RSO stated there would be no adverse effects on the patient. The RSO stated both the patient and the prescribing physician have been notified of the error. The RSO stated that the bulk of the microspheres (activity) remained in the tubing and no contamination was found in the area where the treatment occurred. The RSO stated the physician decided they would perform the procedure again and use the activity needed to bring total activity administered to the activity initially prescribed. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: I-9721 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 54196 | 2 August 2019 17:00:00 | The following was received via e-mail from the Texas Department of State Health Services: On August 2, 2019, the Agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that a radiography crew working at a field site had experienced a source disconnect. The radiographers were using an INC IR-100 exposure device containing a 27 Curie iridium - 192 source. After one of their exposures, they could not return the source to the shielded position. The RSO stated a source recovery team was sent to the site and recovered the source. The RSO stated no overexposures occurred. The RSO stated the recovery team found that the drive cable had broken just behind the drive end connector. The RSO stated they are still investigating the event. Additional information will be provided as it is received in accordance with SA-300. Texas Event Report No: 9699 |
| ENS 54194 | 2 August 2019 11:27:00 | The following was received via e-mail from the Texas Department of State Health Services: On August 2, 2019, the Agency was notified by the licensee's radiation safety officer (RSO) that a radiography crew was unable to retract a 56 Curie iridium - 192 source into a INC R100 exposure device. The radiographers set up a 2 millirem boundary and contacted the RSO. The RSO went to the scene and found that the guide tube had a sharp bend in it and would not let the source pass through the bend. The RSO straightened the guide tube and was able to return the source to the exposure device. No overexposures occurred. The guide tube has been removed from use. Texas Event Report No: 9698 |
| ENS 53679 | 21 October 2018 16:19:00 | The following information was received via E-mail: On October 20, 2018, the agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that one of its radiography crews was unable to return an 80 curie iridium-192 source to the fully shielded position in an INC IR 100 exposure device. The RSO stated that the event occurred near Pecos, Texas. The RSO stated that the radiographers had established a 2 millirem boundary. An individual listed on their license responded to perform the source retrieval. The location where the event occurred was remote and the event did not present an exposure risk to any individual. The RSO stated that there are very few people at the site. Once the individual who was sent to retrieve the source arrived, they inspected the exposure device and guide tube. The inspection discovered the radiographers had bent the guide tube to get it through some pipes and the angle of the bend was what had prevented the source from being retracted. The guide tube was straightened and the source was retracted to the fully shielded position at 2100 hours. The guide tube was inspected and did not have any damage. The RSO stated that no overexposures had occurred. Texas Incident Number: 9622 |
| ENS 53588 | 7 September 2018 17:11:00 | The following information was received from the State of Texas via email: On September 7, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee that during plant maintenance on a vessel, the handle on a Vega model SH-F2 nuclear gauge containing a 70 millicurie (original activity) Cesium-137 source was broken and the shutter was stuck in the half closed (half open) position. The license stated because of the location of the gauge on the vessel it does not create an exposure risk to any individual. The licensee has contacted a service provider to repair the gauge. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: 9611 |
| ENS 53487 | 4 July 2018 23:19:00 | The following information was received from the State of Texas by email: On July 4, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that one of their crews has experienced a source disconnect. The crew was using a QSA 880D exposure device containing a 70 Curie Iridium - 192 source. The licensee did not have a lot of details on the event, but stated the source had been recovered and that no over exposures had occurred. The licensee stated the connector ball on the drive cable was tested after the event and failed the test. The RSO stated they would provide additional information on July 5, 2018. Additional information will be provided as it is received in accordance with SA-300. Texas Incident- I-9591 |
| ENS 53478 | 28 June 2018 10:10:00 | The following information was received from the State of Texas via email: On June 27, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee's corporate radiation safety officer (CRSO) that one of his radiography crew had experienced a source disconnect. The crew was using a QSA 880D exposure device containing a 113.1 Curie iridium - 192 source. After completing the first shot on a new location on the pipeline, the crew could not get the source to return to the exposure device. The crew contacted the CRSO and set up new barriers at 2 millirem. The CRSO and a second individual qualified for source retrieval arrived at the site at 1743 hours. The retrieval team (RT) surveyed the guide tube and determined the source was in the collimator. The RT removed the guide tube from the exposure device and removed the camera from the area. Using a set of long tongs, the guide tube was removed from the pipe and the source slid down the guide tube until the connector was exposed. They could see the drive cable had broken near the connector. The source was shielded with bags of lead shot. The CRSO disconnected the broken drive cable from the source pigtail and connected the pigtail to a new drive cable that had been installed on the camera. The source was retracted to the shielded position in the camera. The camera and crank out device and drive cable will be sent to the manufacturer for inspection. No overexposures occurred as a result of this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident # - 9590 |
| ENS 53439 | 1 June 2018 14:45:00 | EN Revision Text: AGREEMENT STATE REPORT - FAILURE OF RADIOGRAPHY SOURCE TO RETRACT The following information was received via E-mail: On June 1, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee that a radiography crew was unable to retract a 50 Curie Iridium-192 source into an INC 100 exposure device. The crew was working in a remote area in West Texas when they could not get the source to go past the inlet nipple of the exposure device. After a few attempts, the crew contacted the licensee and an individual authorized to recover sources was sent to the site. The licensee did not have specific information on how the source was retracted, but stated it took the individual about 45 minutes to recover the source. The source was returned to the fully shielded position. The exposure device and source were returned to the licensee's storage area and will be sent to the manufacturer for inspection. The licensee stated the exposure device was surveyed and radiation levels were normal. The licensee reported that one individual's 0 - 200 millirem self-reading dosimeter did go off scale. The individual's OSL dosimeter has been sent to the licensee's dosimetry processor for reading. The licensee stated it calculated the individual's dose to be 400 millirem based on an interview with the individual. The licensee stated no individual involved received an exposure that exceeded any limit. No member of the general public received an exposure from this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9578
The following information was received from the State of Texas via email: On June 1, 2018, the licensee reported one of its crews were unable to retract a 50 curie iridium - 192 source to the fully shielded position. The licensee's written report received June 29, 2018, stated one of the radiographers had disconnected the guide tube from the exposure device and saw the source was not in the shielded position. The licensee stated the radiographer would have been in contact with the guide tube for 3-5 seconds. The individuals badge was sent for processing and had a reading of 312 millirem DDE. The licensee's initial calculation for the exposure to the individuals hands was 450 millirem. The Agency questioned the dose assessment to the hand. On July 11, 2018, the licensee's radiation safety officer stated they have contacted a service company to perform the dose calculations for the individuals hands. Pictures of the individuals hands taken on July 11, 2018, show no adverse effects from the exposure. Notified the R4DO (Pick) and the NMSS Events Group via email. |
| ENS 53411 | 18 May 2018 16:08:00 | The following was received from the State of Texas via email: On May 11, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee that an event had occurred. The licensee stated that a patient had been treated with I-131 for thyroid cancer on May 4, 2018. The patient was instructed on the procedure, restrictions, and their responsibility after the treatment. The patient signed a document stating they understood the instructions. The patient was scheduled to return on May 11, 2018, for a whole body scan. The patient was discharged after the radionuclide was administered. On May 11, 2018, the patient failed to show up for his 1000 hours appointment. At 1100 hours, the nurse (nurse one) working the scanner area received a phone call from a floor nurse. The floor nurse asked if they had an appointment for the patient in this event. Nurse one stated they did, but he failed to show up for the appointment. The floor nurse stated that the individual was in their treatment area. Nurse one asked how long he had been there and the floor nurse stated he had been brought to them 4 days prior with an injury from a fall. Nurse one asked why radiology had not been informed and the floor nurse stated they were not aware of his previous procedure. The licensee surveyed the patient and found they were reading above background. The licensee determined areas of the hospital outside the patient's room the patient would have been in and surveyed them. No contamination was found. The licensee removed all material from the patient's room and moved it to its decay room for storage. Access to the patient's room was restricted until it decays to levels not distinguishable from background. The licensee established controls to prevent any further contamination resulting from the patient. The patient was discharged from the hospital to the rehab facility on May 14, 2018. The Agency was not aware that access was restricted to the patient's room until the written report was reviewed on May 18, 2018. Additional information will be provided as it is received in accordance SA-300. Texas Incident #: I-9575 |
| ENS 53391 | 7 May 2018 22:11:00 | EN Revision Text: AGREEMENT STATE REPORT - SOURCE DISCONNECTED FROM GAUGE'S OPERATING ROD On May 7, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that on the night of May 5, 2018, they discovered the 100 milliCurie (original activity) source had disconnected from the operating rod of a Berthold model P2608.100 gauge. The RSO stated a set of tongs were used to remove the source from the vessel and place it in a lead pig designed for the source. The RSO stated the manufacturer has been contacted for assistance in repairing the gauge. The individuals who removed the source from the vessel were wearing dosimetry and the RSO stated they were sending the dosimeters in for processing. The RSO stated they had no reason to believe any individual exceeded any limit. Additional information will be provided as it is received in accordance with SA-300. Texas Incident # 9570
The following was received via e-mail: During the licensee's investigation of this event, the radiation safety officer (RSO) found that the source on a second, almost identical gauge, had also separated from the operating rod. The second gauge, model HPS-1, contains a 500 milliCurie cobalt - 60 source. The failure does not create an exposure risk to any individual. The RSO stated they had received the results for the dosimetry sent for processing from the first reported failure and all readings were 0.0 millirem. The highest lifetime dose for any individual in the report was 105 millirem. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Hay), and NMSS Events Notification via email. |
| ENS 53139 | 29 December 2017 12:13:00 | The following information was received via E-mail: On December 29, 2017, the Agency (Texas Department of State Health Services) received a call from the licensee's corporate radiation safety officer (CRSO) reporting a lost exposure device. The CRSO stated one of the licensee's radiographers at one of their licensed storage locations had placed a QA model D880 exposure device (serial # D15021) containing a 40.9 curie iridium-192 source on the tailgate of the truck at the licensee's Beaumont location. The radiographer left the licensee's location and headed to their work location. When the radiographer reached Groves, Texas, they realized they had not secured the device and pulled over. The device was not on the tailgate. The radiographer contacted the radiation safety officer and a search was begun. The CRSO stated at least two teams are searching the route looking for the device. The distance to be searched is about 20 miles based on the current information. The CRSO stated the device did have both storage caps on the device. The CRSO stated the dose rate on the device was 17 millirem on contact with a TI (Transportation Index) of 0.4. The CRSO stated they have contacted local law enforcement who are responding to the licensee's location. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9528 Notified External: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, and EPA EOC. Notified External via E-mail: Mexico, FDA EOC, NuclearSSA, FEMA National Watch Center, DNDO-JAC.
The following information was received via E-mail: The missing device has been found. Additional information will be provided in accordance with SA-300.
The following information was received via E-mail: The Agency received the following information on the event. The radiographers did not go to Grove Texas, but only made it to Nederland, Texas making the search area between 8 and 10 miles. At the time the device was recovered approximately 40 people were searching for it on foot. The searchers included firefighters, emergency response personnel, and licensee personnel. Pictures of the device show the outer coating was scratched, but the device itself did not appear damaged. Additional information will be provided as it is received in accordance wit SA-300. Notified Internal NRC: R4DO (Haire), NMSS Regional/INES Coordinator (Rivera-Capella), IRD MOC (Grant), ILTAB (Davis), and NMSS Events Notification. Notified External: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, and EPA EOC. Notified External via E-mail: Mexico, FDA EOC, NuclearSSA, FEMA National Watch Center, DNDO-JAC. 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 |
| ENS 53474 | 26 June 2018 17:30:00 | The following information was received from the State of Texas: During the review of an event, the Agency (Texas Department of State Health Services) found a letter from a licensee reporting the shutter on a Ohmart model SHD-45 containing a 50 millicurie cesium - 137 source had failed in the closed position. The report was dated November 29, 2017. The shutter did not pose an exposure risk to any individual. The licensee has worked with the manufacturer and the gauge was scheduled to be replaced on June 21, 2018. The Agency has not been able to confirm if the gauge was repaired/replaced. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9588 |
| ENS 52986 | 22 September 2017 11:36:00 | The following information was received via E-mail: On September 18, 2017, the Agency (Texas Department of State Health Services) received a reciprocity request from a nuclear gauge manufacturer to perform repairs on a Ronan Engineering model SA1-F37 gauge at the licensee's facility. The gauge contains a 500 millicurie (original activity) source. On September 22, 2017, the Agency contacted the licensee and asked if the gauge shutter was functioning properly. The individual stated the shutter on the gauge would not fully close. The individual was instructed to contact the licensee's radiation safety officer (RSO) and instruct the RSO to contact this Agency. The RSO contacted the Agency and stated the problem was discovered when testing the gauge on September 14, 2017. The RSO stated the gauge shutter was not open, but stuck in the closed position. The RSO stated it appears the pin that connects the shutter operating arm to the operating rod is no longer in place and the shutter cannot be moved. The RSO stated the gauge is located in an area where the access is controlled and does not pose an exposure risk to their workers or members of the general public. The manufacturer is scheduled to be on the site September 26, 2017, to repair the gauge. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9511 |
| ENS 52824 | 23 June 2017 16:47:00 | The following information was received via E-mail: This event occurred at a field site in or near Orla, Texas. On June 23, 2017, the Agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that an event had occurred involving one of their radiography crews. The RSO stated while performing radiography operations at a field site, a radiographer had approached a SPEC 150 exposure device (camera) containing an 81 Curie iridium-192 source to disconnect the guide tube. After reaching down to disconnect the guide tube, the radiographer noticed the guide tube was not completely attached to the camera and their exposure device (ND 2000 dose rate meter) was pegged high on the times ten scale. The source was then fully retracted to the fully shielded position. The radiographer stated his hand was in close proximity to the guide for about 10 seconds. The radiographer stated his self-reading dosimeter was reading 52 millirem after the event. The RSO stated the radiographers were on their way back to their office. The RSO stated the TLD badges for radiographers would be sent in for reading by their dosimetry processor. The RSO stated the radiographers would be interviewed and the licensee would inform the Agency on Monday, June 26, 2017, what their investigation revealed. The RSO did not have any additional information. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9496
The following information was received via E-mail: On June 27, 2017, the Agency contacted the licensee and inquired on the status of the radiographer exposed during this event. The licensee's radiation safety officer (RSO) stated they have not seen any changes in the appearance of the radiographer's hands. The RSO stated the radiographer has not felt any discomfort in his hands. The RSO stated a blood sample will be sent to Radiation Emergency Assistance Center/Training Site (REAC/TS) in Oak Ridge, Tennessee, for analysis. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Vasquez), NMSS Events Notification and NSIR (Milligan) by email. |
| ENS 52770 | 24 May 2017 12:20:00 | The following information was received from the State of Texas by email: On October 16, 1998, the Agency (Texas Department of State Health Services) was notified that a Humboldt model 5001 moisture/density gauge containing a 10 millicurie cesium - 137 and a 40 millicurie americium - 241 source was lost during transport from San Antonio to Laredo, Texas. The gauge was to be delivered to the Texas Department of Transportation (TXDOT). A search of the transportation companies warehouses and delivery locations along the transportation route did not find the gauge. The investigation was placed in "Inactive" status. On May 17, 2017, the Agency received an email string showing that a moisture/density gauge was for sale on the internet site 'eBay'. A search of the eBay site found that the gauge serial number matched the serial number of the gauge reported missing in 1998. The Federal Bureau of Investigation (FBI) was contacted and a request was made for assistance in gathering information on the seller. Using the information gathered by the Agency and the FBI, the Agency was able to contact the seller. The seller removed the posting off of eBay immediately. The seller stated they purchase materials from companies who are going out of business and resell them. The seller stated they did not remember when or where the gauge was purchased. The seller stated they had just moved all the materials they store in a large warehouse into two smaller warehouses and that is when they discovered the gauge. They did some research on the use for the gauge online and decided to sell it. The seller turned the gauge over to TXDOT on May 24, 2017. Dose rates taken on the gauge by TXDOT were normal. The gauge will be leak tested and returned to the manufacturer. Additional information will be provided as it is received in accordance with SA-300. Event #35040 initially reported the event on 11/16/1998 as a lost source while in transit. Texas Incident: I-7394 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 52671 | 9 April 2017 13:46:00 | The following information was provided by the State of Texas via email: On April 9, 2017, the Agency (Texas Department of State Health Services) was notified by the licensee's Radiation Safety Officer (RSO) that on April 8, 2017, one of his crew was unable to retract a 95 curie iridium-192 source into a Spec 150 exposure device (at a work site 2 miles inside the Texas border near Jal, NM). The RSO stated that after the first exposure for the day, the radiographers noted they could not lock the source inside the exposure device. The radiographers established a two millirem per hour boundary and evacuated two trailers that were inside the two millirem per hour barrier. The RSO stated the people were in the trailer for five minutes before the radiographers had them leave the area. The radiographers contacted the site RSO who responded to the scene. The site RSO found the guide tube had separated from the front of the exposure device. The site RSO was able to retract the source into the fully shielded position. The RSO stated they believe that sand had built up in the guide tube to camera connection which prevented the guide tube connector to fully seat in the connection. The RSO stated his initial calculations indicated no member of the general public exceeded any exposure limits. No licensee personnel exceeded any exposure limit from this event. Additional information will be provided as it is received in accordance with SA-300." Texas Incident #: I-9478 |
| ENS 52317 | 25 October 2016 15:53:00 | The following was received from the State of Texas via email: On October 25, 2016, the Agency (Texas Department of State Health Services) was notified by the licensee that while preparing to leak test a VEGA Americas, Inc. model SH-F1 nuclear gauge the shutter on the gauge could not be fully closed. Open is the normal operating position of this gauge. The gauge contains a 60 millicurie (original activity) cesium-137 source. The gauge is on the third floor of a vessel and does not present a exposure hazard to workers or members of the general public. The licensee has contacted a service provider to repair the gauge. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I 9434 |
| ENS 51945 | 19 May 2016 22:08:00 | The following information was received via E-mail: Event Type: 30.50(b)(2), Events in which equipment is disabled or fails to function as designed. Event Narrative: On May 19, 2016 the Agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that while performing routine shutter checks, the shutter on an Ohmart model SHLM-BR4 could not be closed. The gauge contains a 5.0 curie cesium-137 source. Open is the normal operating position of the gauge. The source does not create any additional risk of exposure to the workers or members of the general public. The RSO stated they will call their service company to repair the gauge. The RSO stated the gauge is scheduled to be replaced during their next outage this fall. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9405. |
| ENS 51778 | 8 March 2016 09:42:00 | The following was received from Texas via email: On March 7, 2016, the Agency (Texas Dept. Of State Health Services) was notified by the licensee that while performing routine checks, the shutter on an Ohmart SH-F2 nuclear gauge was stuck in the open position. Open is the normal operation position for the shutter. The gauge contains a 100 millicurie cesium-137 source. The gauge does not create an exposure hazard to the licensee's employees or any member of the general public. The licensee has contacted their service company who will inspect the gauge on March 9, 2016. Additional information will be provided as it is received in accordance with SA-300. Texas incident # I-9384 |
| ENS 51407 | 18 September 2015 11:59:00 | The following information was received from the State of Texas via email: On September 18, 2015, the Agency (Texas Department of State Health Services) was informed by the licensee's radiation safety officer (RSO) that a radiography crew had experienced a source disconnect at a temporary field site (Galveston, Texas). The RSO stated the crew was working inside a vessel using a QSA 880D exposure device containing a 52.9 curie Iridium-192 source. The device fell from a distance of 30 feet and hit the floor of the vessel. The source was in the fully shielded position when the device fell. The radiographers noted the guide tube had a small kink in it and replaced the guide tube. The radiographers tested the source by cranking the source out, but when they attempted to retract the source, the drive cable did not stop at the rear outlet of the camera. The radiographers contacted their supervisor and performed a dose rate survey at their barrier. The dose rate was 1 millirem per hour. An individual qualified in source recovery was able to remove the source from the guide tube and place it in a source changer for storage. The RSO stated their inspection of the source drive cable found the connecter on the drive cable had separated from the drive cable. The RSO stated all equipment involved in the event will be returned to the manufacturer for inspection. No individual received an over exposure as a result of this event. No member of the general public received an exposure due to this event. The licensee is conducting an investigation into the event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident: I-9339 |
| ENS 51203 | 7 July 2015 16:20:00 | The following information was received from the State of Texas by email: On July 7, 2015, the Agency (Texas Department of State Health Services-Radiation Branch) was notified by the licensee's radiation safety officer (RSO) that the shutter on a Ronan GS-400 level gauge containing a 50 millicurie cesium - 137 source was stuck in the open position. The stuck shutter was discovered during the start up of a system component. Open is the normal position for the shutter. The gauge does not possess an exposure risk to any individuals. The manufacturer has been contacted and will replace the gauge. Additional information on this event will be provided as it is received in accordance with SA-300. Texas Incident: I-9324 |
| ENS 51000 | 22 April 2015 00:18:00 | The following information was received by the State of Texas via email: On April 21, 2015 at 2209 (CDT) hours, the Agency (Texas Department of State Health Services) was contacted by Andrews County Emergency Management (ACEM). They informed the Agency that an accident had occurred 12 miles south of Andrews, Texas, on highway 385, which involved a radiography truck. The Agency contacted ACEM chief who stated he was at the scene of a three vehicle accident which included a truck from Desert NDT. The driver was killed in the accident and the truck cab had separated from the frame. He stated the dark room had separated from the truck bed. He stated a person from the Andrews County WCS (Waste Control Specialist) was there and had performed a radiation survey and measured a dose rate of 15 millirem 10 feet from the truck. He stated the licensee had been contacted. He stated they had taken care of the survivors and had backed out of the area until the licensee's radiation safety officer arrived on the scene. He stated they had not seen the shipping papers, only the radiation symbol on the truck. I asked him to have the licensee contact the Agency as soon as they arrived on site. The licensee's (Desert NDT) RSO arrived at the scene at 2223 hours and contacted the Agency. He stated his priority was to locate the source. He agreed to call the Agency as soon as he had control of the source. At 2240, the RSO contacted the Agency and stated he had control of the source. The iridium source was inside a INC 100 radiography camera and the RSO believed the activity was between 20 and 26 curies. He stated the camera did not appear to be damaged. He stated the dark room had separated from the truck and split into two pieces. The camera was located still in its transport box in a section of the darkroom. He stated the dose rate on contact with the camera was 16 millirem an hour and 0.4 millirem at 1 foot. The dose rate at 1 meter was not distinguishable from background. He stated no individual at the scene would have received an exposure to radiation that would have exceeded any limits. The RSO stated he was taking the source back to the licensee's office for storage. The RSO stated they would send the exposure device to the manufacturer for inspection. Additional information will be provided as it is received in accordance with SA-300. Texas Incident: I-9305
The following information was received by the State of Texas via email: The licensee's corporate radiation safety officer contacted the Agency (Texas Department of State Health Services) and informed them that two radiographers were killed in this event. He stated the source activity was only 13 curies. He stated that local law enforcement in Andrews, Texas will not release any details of the accident until their investigation is completed. Additional information will be provided as it is received in accordance with SA-300. Notified the R4DO (Drake), IRD MOC (Gott) and the NMSS Events Notification via email. |
| ENS 50838 | 20 February 2015 13:14:00 | The following information was received from the State of Texas via email: On February 20, 2015, the Agency (Texas Department of State Health Services) was notified by the licensee that on February 19, 2015, one of its radiography crews working at a remote field site (near Kennedy, Texas) was unable to retract a 31.9 Curie Iridium 192 source into a QSA 880D exposure device. The radiographers were examining a pipe on a pipe pad with the collimator being held in place with a magnetic stand. As the radiographer began to retract the source after a shot, the stand fell and struck the source guide tube crimping the tube to a point where the source could not be moved. The radiographers stopped work in the area and moved their boundaries to prevent exposures to members of the general public. The radiographers contacted their radiation safety officer (RSO), but he was located 8 hours from the work site. The RSO contacted the licensee's office in Corpus Christi, Texas and the RSO from that location responded to the event. The Corpus Christi RSO is (at the location) to perform source retrieval. The event occurred at 1630 (CST) and the source was retracted at 2400 (CST). No over exposures occurred and no member of the general public received any additional exposure from this event. The guide tube has been removed from service for inspection. The dosimetry badges for the individuals involved in the event have been sent to the licensee's processor for reading. The licensee is investigating the event. Additional information will be provided as it is received in accordance with SA-300. On February 20, 2015, the licensee agreed to send the source involved in this event to the manufacturer for inspection. Texas Incident: I-9281 |
| ENS 50366 | 14 August 2014 11:07:00 | The following information was provided by the State of Texas via email: On August 14, 2014, the Agency (Texas Department of State Health Services) was notified by the licensee's Radiation Safety Officer (RSO) that on August 13, 2014, a radiography crew using a 50 foot crank out device could not retract a 54 curie iridium-192 source to the fully retracted and locked position in a QSA 880D exposure device (camera). The RSO stated the radiographer had completed an exposure at a temporary field site and was retracting the source when he felt the resistance to movement in the crank out handle disappear and he could no longer move the source. The radiographer noted the dose rates were still higher than those for a fully shielded source. The radiographer contacted the RSO and increased the control area. The radiographer placed two bags of lead on the guide tube where he believed the source was located. The RSO stated the radiographer was in the area of the source for just a few seconds. The radiographer checked his self reading dosimeter after placing the lead at the source and found it off scale. The RSO and a recovery team went to the location to retrieve the source. The RSO had additional lead placed on the guide tube and the dose rates at the crank out device dropped to less than 2 millirem per hour. The RSO disconnected the drive cable housing from the broken in two at crank out device. The RSO grabbed the drive cable inside the drive cable housing with a set of pliers and was able to pull the drive cable and return the source to the fully shielded position. The personnel dosimeter for the radiographer who had approached the guide tube was sent to the licensee's dosimetry processor for processing and the radiographer has been removed from all work involving exposure to radiation until the results for their badge has been received. The RSO stated that based on the exposure rates and the time the radiographer was in the area of the source he did not believe the radiographer received a significant exposure from the event. The RSO received 8 millirem by pocket dosimeter from the event. No other individuals received any significant exposure in this event. The crank out and drive cable will been sent to the manufacturer for inspection. The RSO stated he examined the drive cable, but did not see anything that would indicate why the cable failed. The RSO stated they performed a flex test of the drive cable and it passed. The RSO stated the camera and guide tube were inspected and returned to service. Additional information will be provided in accordance with SA-300. Texas Incident #: I-9219 |
| ENS 49899 | 11 March 2014 21:43:00 | The following was received via email from the State of Texas: On March 11, 2014, the Agency (Texas Department of State Health Services) was notified of the theft of a Humboldt model 5001EZ moisture density gauge containing an americium-241 source and a cesium-137 source by the licensee. The licensee did not know the activity of the sources. The licensee stated a technician was working at a job site taking measurements every thirty minutes. The technician placed the gauge on the bed of their truck after taking a reading and left it there to talk to the site foreman. When they came back to the truck the gauge was missing. The technician and site foreman looked for the gauge, but did not find it. The technician notified his supervisor who notified the licensee's Radiation Safety Officer. The licensee stated they intend to notify the service providers they use of the theft. The licensee stated the operating rod for the cesium source was locked. Additional information will be provided as it is received in accordance with SA-300.
On March 12, 2014 at 0745 (CDT), the Agency was notified by the licensee that the moisture density gauge had been recovered. The licensee had limited information on how the gauge was located and stated they will provide additional information as soon as it can be collected and verified. It did not appear to the licensee that any member of the general public received a significant exposure due to this event. Additional information will be provided to the HOO as it is received in accordance with SA-300. Notified the R4DO(Farnholtz), FSME Events Resource via email and Mexico. Texas Incident # I-9166 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 42410 | 13 March 2006 12:40:00 | The following information was received via fax: On Friday evening we received a call from the (after-hour phone) service with instructions to call the SOC concerning a lost nuclear gauge. There were instructions to call (the) RSO for Pre-Test Lab (TXRAML02524) a licensee based in Georgetown, TX with authorization to possess and use a variety of moisture/density (M/D) gauges. The RSO explained that around 1500 hrs on Friday, March 10, 2006, one of his trucks was proceeding to a convenience store in the vicinity of Red Bud and County Road 122 in Round Rock, TX when upon arriving at the store it was noticed that the M/D gauge was missing. He admitted that the tailgate may not have been secured and the shipping container was not chained to the bed of the truck. An extensive search of the area traveled was conducted by Pre-Test as well as Round Rock PD and FD without finding the container. The device is a Troxler Model 3411-B serial number (S/N) 10260 with a 9mCi (milliCurie), Cs-137 source model TEL Dwg. #102112 , S/N 40-7662 and a 44mCi, Am-241source model TEL Dwg. #102451, S/N 46-1663. Texas Incident No.: I-8312 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. |