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| Entered date | Event description | |
|---|---|---|
| ENS 53155 | 8 January 2018 16:40:00 | The following information was received via E-mail: On January 8, 2018, the Agency (Texas Department of State Health Services) received a report from the licensee's radiation safety officer (RSO) stating the shutter on an Ohmart Vega model SH-F1 gauge, containing a 60 milliCurie cesium-137 source, failed to shut during an operational check. Open is the normal operation position of the gauge shutter. No licensee employee received any exposure as a result of this event. The gauge was repaired the following morning. An investigation into this event is ongoing. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9529 |
| ENS 52595 | 7 March 2017 11:32:00 | The following was received by email from the Texas Department of State Health Services: On March 7, 2017, the Agency (Texas Department of State Health Services) was contacted by a representative of the licensee to report that on the previous day a gauge was found to have a stuck shutter. The gauge is a Berthold LB 7442D with a 30 mCi Cs-137 source. The shutter is stuck in the normal operating position. The licensee is in contact with the manufacturer for a repair plan and with licensing for an exemption to operate the gauge temporarily with a stuck shutter. No exposures to the public are expected. Additional information will be shared as it becomes available in accordance with SA-300. Texas Incident #: I-9470 |
| ENS 52540 | 8 February 2017 13:28:00 | The following report was received via e-mail: On February 8, 2016, the Agency (Texas Department of State Health Services) was notified by the licensee (a nuclear pharmacy) that three packages received were contaminated with radioactive material. The contamination does not seem to have come from the contents of the packages themselves, the receiving facility, or the origin facility. Additional information will be shared as it is received in accordance with SA-300.
The following report was received via e-mail: On February 8, 2016, the Agency (Texas Department of State Health Services) dispatched an inspector to the licensee's facility to investigate. No additional contamination was found in the licensee's facility. No likely sources of contamination for the packages were identified. The truck and driver that had delivered the packages was intercepted by the shipper and redirected back to the licensee's facility. The truck and driver were surveyed for fixed and removable contamination. No contamination was found on the truck, driver, or associated equipment. Additional information will be shared as is received in accordance with SA-300. Texas Incident #: I - 9462 Notified R4DO (Warnick) and NMSS Events Notifications via email. |
| ENS 52439 | 15 December 2016 15:38:00 | The following was received from the State of Texas via email: On December 15, 2016, the Agency (Texas Department of State Health Services) received notice that the licensee had retrieved a source disconnected via a broken drive cable. The camera was an 880 Delta with a 135 curie iridium-192 source. The retrieval agent received an estimated 113 mRem to the whole body and 1 Rem to the hands for the procedure. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I - 9450 |
| ENS 52333 | 31 October 2016 09:09:00 | The following report was received via e-mail: On October 26, 2016, the Agency was notified that two exit signs had been found missing during inventory. The licensee was contacted and asked to provide additional information including when the discovery was made and activity contained. The licensee's subsequent email revealed that the signs contained 0.426 TBq each of tritium. The signs had been discovered missing in April of 2016. The disposition of these signs is unknown. Additional information will be provided in accordance with SA-300. Texas event : I-9436 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 51761 | 1 March 2016 13:22:00 | The following Agreement State Report was received from the State of Texas via email: On March 1, 2016, the Agency (Texas Department of State Health Services) received notice that on February 29, 2016, the licensee had discovered that a Berthold fixed gauge model MB7442D containing 30 milliCuries of cesium-137 had malfunctioned. The shutter was stuck in the open position. The gauge is normally left in the open position, and no exposure to the public is likely. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I 9383
The following updated report was received from the State of Texas via facsimile: The following information was provided by the manufacturer: Celanese of Bishop, TX contacted Berthold in early March (2016), to come out and repair a LB 7442 device with a broke shutter. This device was one of many that was sold by BSI until they went out of business in (approximately) 2003. The cause of the broke shutter was corrosion that had built up on the brass shutter shaft making it hard to turn. When the Berthold service engineer was replacing the shaft he noticed that the source holder did not have a lock washer between the source holder and the source. The missing lock washer was not the cause of the broke shutter but has been an issue in the past with a plant in Wyoming that had some of the older BSI devices. Vibration caused the source to come lose from the source holder, the source dropped down into a position that prevented the shutter mechanism from cutting off the radiation beam when rotated which resulted in continuous high readings. Berthold worked with the NRC and the Wyoming plant to inspect the remaining shields to see if there were others that were missing the lock washer. It was noted that some did in fact have the lock washer in place but some did not. The sources that did not have lock washers on them were disassembled from their source holder and lock washers were added. (The manufacturer has) not seen any other records of this happening except for the FMC Corp plant in Wyoming in 2010. At Celanese, the Berthold service engineer removed the source from the source holder and added a lock washer before placing it back into the shield. It was noted by the Berthold service engineer that Celanese appeared to have more of the same devices from that era. The issue in Wyoming could have been an isolated incident but definitely worth noting. Notified R4DO (Kellar) and NMSS Events Notification. |
| ENS 51748 | 22 February 2016 14:04:00 | The following was received from Texas via email: On February 22, 2016, the Agency (Texas) received notice that while under reciprocity in Louisiana, the licensee had lost a Thermo Fisher model 5192 (sn B8191) with 200 milicuries of Cesium-137 (sn 5854CP). Exposure to the public is unlikely due to the design of the device. It is not known whether the device was lost or stolen. The Louisiana Department of Environmental Quality is conducting the investigation. Addition information will be provided as it is received in accordance with SA-300. The device was lost in Louisiana but reported to Texas by a Texas licensee. The state of Texas notified the state of Louisiana and the NRC. Louisiana will conduct an investigation of the issue. Texas Incident # I-9380 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 51647 | 12 January 2016 11:31:00 | The following information was provided by the State of Texas via email: On January 12, 2016, the Agency (Texas Department of State Health Services) received notice that on January 11, 2016, a radiography source could not be retracted to the shielded position. The camera was an 880D with a 99.8 curie Iridium-192 source. An extension to the guide tube had not been connected, and the drive cable slipped the gears of the crank assembly. The drive cable and crank assembly were reassembled and the source was returned to the shielded position. No overexposures resulted from this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9370 |
| ENS 51366 | 3 September 2015 15:29:00 | The following information was received from the State of Texas via email: On September 3, 2015, the Agency (Texas Department of State Health Services) received a report from the licensee that a radiography source retraction failure occurred at a temporary field site in Borger, Texas. A mount fell on the guide tube, crimping the tube. The source was retrieved according to license conditions and the damaged equipment was removed from service. The camera was a SPEC-150 and the source was 78 curies of Iridium-192. No exposure to the public occurred. Further information will be provided as it is obtained in accordance with SA-300. Texas Incident #: I-9336 |
| ENS 51050 | 7 May 2015 12:52:00 | The following information was provided by the State of Texas via email: A representative of the licensee called (the Texas Department of State Health Services) and stated that two weeks ago a Troxler 3430 (sn 24971) had gone missing. He (the licensee) could not find it after calling his service companies and employees. He further said that the serial numbers for the sources are 75-3877 and 47-17874. He does not know what the activity of these sources is. He says that he will begin a written report. Further information will be provided in accordance with SA300 guidelines. The licensee notified the Houston Police Department (report #0496748-15). Texas Incident #: I-9312 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 50501 | 1 October 2014 14:43:00 | The following information was obtained from the State of Texas via email: On October 1, 2014, the Agency (Texas Department of State Health Services) received notice that on September 30, 2014, a radiography source disconnect had occurred at a temporary field site in east Houston. The camera was a Sentinel 880D (s/n D6746) with 68.3 curies of selenium-75 (s/n SE3877). The port cover had not been opened and the source had not been connected to the drive cable. Upon crank-out, the source was stopped at the port cover and could not be retracted. Retrieval was done by pushing the source back in via another drive cable from the other side. The person doing the retrieval received 38 mR to the body and 98 mR to the hand according to pocket dosimeters. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9240 |
| ENS 50399 | 25 August 2014 17:21:00 | The following was received from the State of Texas via email: On August 25, 2014, the Agency (State of Texas) received notice that a dosimetry badge for a radiographer trainee had come back with an exposure of 8.6 roentgen for the period of July 5 to August 4, 2014. The individual has stated that he dropped his badge during work and picked it up later. The trainer working with the trainee received 210mR for the same period. The trainee worked 10 days with the company in all. Currently awaiting written statements from trainee and trainer and further reports from dosimetry provider. Additional information will be provided in accordance with SA-300. Texas Incident #: I-9225 |
| ENS 50317 | 29 July 2014 08:16:00 | The following information was obtained from the state of Texas via email: On July 28, 2014, the Agency (Texas Department of State Health Services) received notice that a radiography source retraction failure had occurred at a temporary field site (Houston) on July 26, 2014. The guide tube had separated at the crimp between the flexible portion and the fitting to the camera. The flexible portion had pushed out when the source was cranked out. The source was retrieved by manually pulling the drive cable back through the camera. The guide tube was removed from service and replaced. The camera was a Sentinel 880 Delta with about 40 curies of selenium-75. No overexposures resulted from this event. An investigation into this event is ongoing. Additional information will be supplied as it is received in accordance with SA-300. Texas Incident #: I-9215 |
| ENS 50171 | 4 June 2014 09:38:00 | The following information was received by the State of Texas by email: On June 3, 2014, the Agency (Texas Department of State Health Services) received notice that the licensee had a damaged Berthold LB300ML gauge (S/N 10004). The gauge had been hit with molten steel and damage had been done to attachment points ('ears') for a locking mechanism and carrying handle. No damage to the 2.5 milliCurie cobalt-60 source (S/N 1374-07-11) or the gauge shutter occurred. The gauge is scheduled for repair on June 5, 2014. Additional information will be supplied as it is received in accordance with SA-300. Texas Incident: I-9198
On June 23, 2014, the Agency (Texas Department of State Health Services) received a written report from the licensee stating the gauge shutter was not damaged during this event. The licensee stated they were able to close the shutter at the time of the event. The gauge was placed in a locked storage box. The manufacturer has completed repairs to the gauge and the gauge has been returned to service. The licensee stated no additional exposure was received by their employees or members of the general public. "Additional information will be provided in accordance with SA-300. Notified R4DO (Allen) and FSME Events Resource email. |
| ENS 50094 | 8 May 2014 10:44:00 | On May 7, 2014, the Agency (Texas Department of State Health Services) received notice that a source retraction failure had occurred on May 6, 2014 around 10 o'clock PM. The camera was a QSA Global 880D (sn D11607) with a 46 curie iridium-192 source (sn 12764C). The guide tube had fallen off of the guide tube stand and crimped. The source was retrieved by the licensee by uncrimping the guide tube. No overexposures resulted from this event. The guide tube was removed from service. All other parts are removed from service pending inspection by the licensee. Texas Incident Report: I-9190 |
| ENS 50041 | 17 April 2014 08:53:00 | The following information was received from the State of Texas via email: On April 16, 2014, the Agency (Texas Department of State Health Services) received notice that on April 15, 2014, a radiography source disconnect had occurred at a temporary field site in or near Martinsville, Texas at approximately 4:45 PM. The camera was a QSA 880D with a 22 curie iridium-192 source. The source was retrieved. No exposure to the public resulted from this event. The cause of failure is unknown at this time, but a crank malfunction is suspected. Additional information will be supplied as it is received in accordance with SA-300. Texas Incident #: I-9184 |
| ENS 49886 | 10 March 2014 11:14:00 | The following was received from the State of Texas via email: On March 10, 2014, the Agency (State of Texas) received notice of a radiography source disconnect that occurred on March 6, 2014. The source was a 92.2 curie iridium-192 radiography source. The event occurred at a temporary field site just south of the border with New Mexico near Carlsbad, NM on the Texas side. No exposures to the public resulted from this event. No overexposures resulted from this event. The cause of the event is unknown at this time. The source was retrieved by the licensee. The licensee's initial report to the Agency (State of Texas) was later than 24 hours after the event. Additional information will be supplied as it is received in accordance with SA-300. Texas Incident #: I-9163
The Agency's investigation of this event has determined that there was no source disconnect, but that the radiographer failed to connect the source pigtail to the drive cable prior to connecting the drive assembly to the exposure device. Additional information will be provided in accordance with SA-300. Notified R4DO (Gaddy) and FSME via email.
On April 29, 2014, the Agency received the final dose information for the radiographer who picked up the guide tube with the source still in it. A dose of 15.11 rem was assigned to his hand that picked up the guide tube and he received 509 millirem DDE on his whole body badge. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Haire) and FSME Events Resource. |
| ENS 49793 | 5 February 2014 13:52:00 | The following information was obtained from the State of Texas via email: On February 5, 2014, the Agency (Texas Department of Health) received notice that on February 3, 2014, the licensee was unable to retract an 84.5 curie iridium-192 source. The camera and guide tube had fallen from a 22 inch pipe while in use. This caused damage to the guide tube near the camera. The source was retrieved according to license conditions. The retrieval employee received 9 millirem from the retrieval. No member of the public was exposed at rates above limit. The damaged equipment was retired from service and will be replaced. The camera was an INC IR-100 with serial number 7231 and the source had serial number 11337C. Additional information will be provided when it is received in accordance with SA-300. Texas Incident Number: I-9154 |
| ENS 49775 | 29 January 2014 15:39:00 | The following was received from the state of Texas via email: On January 29, 2014, the Agency (Texas Department of State Health Services) received notice from the Licensee that a Troxler model 3430 moisture/density gauge had been stolen along with a truck. The serial number is 35379. It was not believed that the gauge was the target of the theft. The truck was stolen from the parking lot while the driver was running an errand. The gauge as manufactured contains an 8 millicurie cesium-137 source and a 40 millicurie americium/beryllium source. An investigation into this event is ongoing. It is unlikely that a member of the public will be exposed to hazardous radiation as the sources are still locked in the shielded position. Additional information will be supplied as it is received in accordance with SA-300. The local police and the Texas Association of Pawnbrokers were notified. Texas incident # I 9150 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 49983 | 1 April 2014 15:47:00 | The following information was received from the State of Texas via email: On March 26, 2014, the Agency (State of Texas - Department of State Health Services) received information that a source disconnect had occurred in November of the previous year. A subsequent report from the licensee received April 1, 2014 indicates that the disconnect occurred on November 12, 2013 at a temporary field site just west of Wink, Texas. The drive cable had become worn, allowing the source to be pushed out without being fully engaged with the pigtail. The source was pushed out of the guide tube but did not retract when the drive cable was cranked in. The camera was a QSA Model 880D S/N D6125, source QSA Global model A424-9 Ir-192 at 66.7 Ci, S/N 99589B. The source was recovered without further incident by attaching another drive cable. No exposure to the public resulted form this event. Additional information will be supplied as it is received in accordance with SA-300. Texas Incident Number: I-9174 |
| ENS 49421 | 9 October 2013 17:30:00 | The following report was received from the State of Texas via email: On October 9, 2013 at approximately 1445 CDT, the Agency (Texas Department of State Health Services) received notice by phone that the licensee had lost a Troxler 3430 (sn 28350) moisture/density gauge near the Donna International Bridge near Donna, Texas. The sources contained within are an 8 mCi Cs-137 source (QSA Global X1218 sn 7502362) and a 40 mCi Am-241/Be source (QSA Global AX1 X.1 X.1/2 sn 47-25061). The gauge had been left on a tailgate out of its transport container when the truck left the temporary job site at approximately 0930 CDT. Upon reaching the first light in town approximately 5 miles away, the driver/technician noticed the down tailgate and missing gauge. A search is still underway. Texas Report # I 9123 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 49346 | 16 September 2013 13:49:00 | The State of Texas submitted the following information via email: On September 16, 2013, the Agency (Texas Department of State Health Services) received notice that one of the licensee's fixed gauges had a stuck shutter. This (stuck shutter) had been discovered during the morning shutter check that morning. The licensee is in contact with the manufacturer for repair. The gauge is a Ronan SA-1 and contains a Cesium-137 20 mCi source, with serial # M3824. The licensee is compiling a written report and is acquiring authorization to operate while awaiting repairs. Additional information will be provided as it is received in accordance with SA-300. Texas State Report # I 9115 |
| ENS 49226 | 30 July 2013 17:45:00 | The following information was received via E-mail: On July 30, 2013, the Agency (Texas Department of State Health Services) received a call from the RSO of Fugro Consultants, Inc. regarding a source retraction failure on July 29, 2013. The licensee had a temporary industrial radiography site in Houston, Texas. The IR-192 source was in an INC IR-100, serial number 7231. The source was unable to be retracted due to a malfunction with the safety latch plate engaging before the source was retracted. The RSO received a call about the problem at 2000 CDT that evening and travelled to the site. The source was retrieved according to the conditions of the license. The RSO determined that no overexposures resulted to the crew, nor were there exposures to the public, resulting from the event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I 9100. |
| ENS 48857 | 27 March 2013 11:47:00 | The following information was obtained from the State of Texas via email: On March 27, 2013, the Agency (Texas Bureau of Radiation Health) was notified by the licensee that a radiography (camera) guide tube at a temporary field site had suffered damage, causing the source to become unretractable. The source was recovered by the licensee according to the terms of the license. The source was part of a GRP model 880D Sentinel radiography camera, S/N 9185. The source was a 51 Ci Ir-192 sealed source, S/N 91313B. Initial dose estimates show 1.4R exposure to whole body and 2R exposure to the hand by the retrieval worker. The work site was closed so no dose was received by members of the public. More information will be provided as needed per SA300. Texas Incident # I-9060 |
| ENS 48490 | 7 November 2012 14:57:00 | The following was received from the State of Texas via email: On November 7, 2012, the Agency (State of Texas) was notified by the licensee that one of its Troxler model 3411B moisture/density gauges had been damaged. The gauge contained one 8 milliCurie cesium-137 source and one 40 milliCurie americium-241/beryllium source. The operator had stepped aside to a nearby wall to get location information. A bulldozer operator assumed that this meant that the test was finished and drove into the area, impacting the gauge. The gauge was not run over, but suffered a bent top and damaged electronics. The licensee performed a survey and determined that the integrity of the sources and shielding were not impacted. The licensee has performed a leak test and will be returning the device to the manufacturer for evaluation. The investigation into this event is ongoing. Texas Incident Number: I-9009 |