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EN Revision Text: AGREEMENT STATE REPORT - FIXED GAUGE STUCK SHUTTER The following was received from the State of Texas via email: On December 19, 2018 at 10:49 am, the licensee's radiation safety officer reported a stuck shutter on a fixed gauge, found during routine maintenance. Gauge is in the open operating position; no employee or public exposures are anticipated. Gauge is attached to a vessel located several feet off the ground. Device information: source SN 8423CN, model SH-F1B, Cs-137, 100 mCi. A service company has been called to repair the gauge. Update will be sent in accordance with SA300 guidelines. Texas Incident #: I-9646

• * * UPDATE ON 01/30/2019 AT 1135 EST FROM MATTHEW KENNINGTON TO JEFFREY WHITED * * *

The following update was received from the State of Texas via email: On January 29, 2019, the licensee's Radiation Safety Officer (RSO) reported to the (Texas Department of State Health Services) that after further investigation two additional gauges were found on December 19, 2018, with shutters stuck in the open position. Open is the normal operating position. The gauges are Ohmart Vega model SH-F1B serial number 8431CN and 8443CN, both containing 100 mCi of cesium (Cs)-137. The RSO stated he discovered the additional shutter failures after reviewing reports received on January 21, 2019. The gauges are located on towers, not easily accessible, and are unlikely to cause unintended exposure. The RSO has contacted a service company and is anticipating the repairs completed to all three gauges in the next week. The RSO intends to apply grease to O-rings to prevent moisture from entering and fouling the shutter mechanism. Notified R4DO (Werner) and NMSS Events Notification via email.

The following report was received from the Texas Department of State Health Services via email: On March 23, 2017, (at 1545 CDT) a consulting company called the Agency (Texas Department of State Health Services) to report that on March 22, 2017, during (a) six month inspection of devices, four devices were found with stuck shutters. Two Ohmart Vega devices contained cesium-137, models SHLG with source serial numbers SM-6918 (120 milliCuries) and 5811GK (5000 milliCuries). The other two were (the) same manufacturer, same isotope, but model SHF2 with source serial numbers M-0076 and M-0077 at 200 milliCuries each. The consulting service is in contact with the licensee's radiation safety officer who is submitting a request to amend the license maintaining the devices in the open position until repaired. No exposures are anticipated and the repairs should be performed within the next 90 days. Updates will be provided as received. Texas Incident #: I 9473

• * * UPDATE ON 4/12/17 AT 1416 EDT FROM ART TUCKER TO DONG PARK * * *

The following information was provided by the State of Texas via email: On April 12, 2017, the Agency (Texas Department of State Health Services) was notified by the licensee that part of its corrective actions in response to this event was to inspect all the gauge shutters again to insure proper operation. The inspection was done on April 11, 2017. During this inspection, two additional gauge shutters were found stuck in the open position. Both gauges are Ohmart model SH-F2 gauges one with a 30 millicurie cesium-137 source, and the second one contains a 100 millicurie (cesium-137) source. No member of the general public or employees at the facility will receive any additional exposure from this event. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Kramer) and NMSS Events Notification via email.

• * * UPDATE ON 4/21/17 AT 1628 EDT FROM ART TUCKER TO DONG PARK * * *

The following information was provided by the State of Texas via email: The Agency (Texas Department of State Health Services) received inspection reports from the licensee and has identified two additional gauges, one SHGL-1 and one SHGL-2, that were found to have shutters that would not close. This inspection occurred in October, 2015. The gauges were reported as functional on the next inspection in April of 2016. The Agency has requested additional information on the gauges. The Agency will be performing an on-site inspection on May 4, 2017. The licensee has replaced the radiation safety officer. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Azua) and NMSS Events Notification via email.

The following report was received from the Texas Department of State Health Services via email: On November 3, 2016, the Agency (Texas Department of State Health Services) was contacted by the licensee's radiation safety officer (RSO). The RSO was reporting that two radiographers had experienced a radiation dose causing pocket dosimeters to go off scale. The crew were working at a temp job site on a power plant. The camera had a 36 curie Ir-192 source. The crew could not hear the alarming rate meters due to excessive noise. The radiographers noticed the source had not retracted completely into the camera while trying to disconnect the guide tube to move the camera to another location. The radiographer reported to the RSO that the source was retracted immediately after finding the source extended. The time reported to the RSO with the source exposing the radiographer was less than 3 minutes. The pocket dosimeters were checked outside the area and found off scale. The RSO stopped all work, requested radiographers return to the shop and he checked the camera to find no defects. The RSO has sent the monitoring badges in for processing and is in the process of completing an investigation to determine exposure dose. A complete report will be provided by the RSO. Updates will be provided in accordance with SA 300 guidelines. Texas Incident #: I 9437

• * * UPDATE FROM IRENE CASARES TO JOHN SHOEMAKER AT 1613 EST ON 12/13/16 * * *

On November 3, 2016, the Agency received a call stating that a radiography crew had experienced an incident on November 2, 2016. The crew had been working at a Power Plant near Franklin, Texas when they experienced an incident involving a possible overexposure. The radiographers were working in a noisy area with all monitoring devices on their person. They had performed several exposure shots and were completing the last shot on a pipe before moving the camera to the next weld area. The radiographer had cranked in the source and both walked to the weld to discuss the next shot position. They were about five feet from the camera and behind the camera which was partially shielded by conduit and piping. Then one radiographer walked to the camera and using the quick disconnect, disconnected the guide tube. When he did this he noticed he source protruding from the camera about six inches and yelled at the other radiographer to get back away from the area. Both ran to the crank, one grabbed the survey meter and the other then cranked in the source, about a turn and half on the crank to secure the source in the camera. The source was in the camera. Both checked their alarming rate meters which were alarming and the pocket dosimeters were off scale. They called the RSO and then packed up their equipment for the day. An incident report was completed at the power plant before leaving the site. Once back at the radiography headquarters the badges were collected and mailed for processing. Both radiographers were interviewed by the RSO and then suspended until monitoring results were received. The RSO calculated the dose to be 1593 mrem for the one radiographer's hand dose.

"Monitoring badge results were reported to the Agency on November 10, 2016, with a whole body dose of 309  mrem and a whole body dose of 317 mrem.  The  annual dose for both radiographers was provided with results of 2053 mrem and 2761 mrem.  The November badges had been worn for two days when the incident occurred.   

"A re-enactment investigation was conducted on November 29, 2016, due to limited details on the report  provided by the RSO and the calculations appeared to be short in dose.  The investigation and interviews with the radiographers on November 29, 2016, revealed the dose to the hand, foot, gonads, knee, and whole body were slightly higher dose but still under the limits for an overexposure.  We had calculated the dose to the hand to be approximately 29 rem instead of 15.9 rem reported by the RSO.  The distance of the hand dose was provide by the RSO at 4 inches, during the re- enactment, a smaller distance of one half inch during the time the radiographer removed the guide tube was more accurate.  His hand passed directly over the source when he pulled the guide tube over the source when it was extended from the camera.  The shorter distance increased the dose, however was still under the 50 rem limit for an overexposure.  The radiographer has not experienced any redness, blisters or soreness to his hand.  He has been viewing his hands daily and has not notice any radiation burn or injury.  During the  investigation his hands were viewed and no noticeable damage was seen (26 days after the incident).

"The cause of the incident was not retracting the source completely into the shielded position and not using a  survey meter to ensure the source was shielded.  The two radiographers had changed positions during this job.  One usually worked the crank and the other collected the film.  Neither radiographer heard the alarms on the rate meters due to the noise.  Both radiographers commented during the investigation, that they weren't using the meter like they should and it was their fault for not doing the required survey.  Violations were cited to company and radiographers.

Notified R4DO (Kellar) and NMSS Events Notification via email.

• * * RETRACTION FROM IRENE CASARES TO VINCE KLCO ON 4/10/17 AT 1253 EDT * * *

The following information was received from the State of Texas via email: (The Texas Department of State Health Services) would like to retract NRC event number 52345. At the initial reporting from the regulated entity, it was believed two radiographers had received an overexposure from a non-retractable source. After further investigation, it was not a non-retractable source, such as equipment failure. It was human error and the source was retracted by the radiographer. There was no equipment failure. It was operator error and the dose that both radiographers received was not over the reporting limits. Please retract this event. Summary: On November 3, 2016, the Agency was contacted by the licensee's radiation safety officer (RSO). The RSO was reporting that two radiographers had experienced a radiation dose causing pocket dosimeters to go off scale. The crew were working at a temp job site on a power plant. The device was a Spec 150, serial 1500, Spec source G60, serial XG2601 with of Ir-192 with 36 curies of activity. The monitoring badges were sent for processing with results of 317 and 309 mrem doses. The annual dose for both radiographers was below the 5 rem limit. The calculations for the extremity dose (hand, foot, and knee) were below the 50 rem overexposure limit. The annual dose for both radiographers was provided with results of 2053 mrem and 2761 mrem. A re-enactment investigation was conducted on November 29, 2016 due to limited details provided by the RSO. The dose was calculated at 29 rem to the extremities which is under the limit 50 rem for reportable event. The cause of the incident was not retracting the source completely into the shielded position and not using a survey meter to ensure the source was shielded. To prevent recurrence, the company had a meeting (training) with employees stressing the importance of safety, following procedures, and being aware of surroundings. One violation cited to the company and each radiographer." Notified the R4DO (Kramer) and NMSS Events Notification via email

The following report was received from the Texas Department of State Health Services via facsimile: On June 1, 2016, the licensee notified the Agency (Texas Department of State Health Services) that one of its shipments was involved in a transportation accident. A carrier was transporting two type A packages, each containing a vial of fluorodeoxyglucose (F-18), 10 mCi, when it was involved in an accident on an unreported freeway. Emergency responders arrived at the scene, the driver was taken to a hospital. The vehicle was cleared from the roadway. It is uncertain at this time where the vehicle or the packages are located. The licensee is obtaining information to recover the radioactive materials. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I 9408

• * * UPDATE AT 1703 EDT ON 6/1/16 FROM ART TUCKER TO JEFF HERRERA * * *

The following report was received from the Texas Department of State Health Services via email: Agency (Texas Department of State Health Services) received call 1529 CDT from licensee. He informed us (Texas) that the packages were intact, not damaged, and recovered from the accident vehicle. The packages are currently located at the original pharmacy location in Dallas. The vial activity amount was 15 mCi each instead of the reported 10 mCi. The licensee stated that since the driver was not his employee he could not obtain information on the driver. The packages were intact and no exposures occurred. Notified the R4DO (Deese), NMSS Events, and Mexico (via email).

• * * UPDATE AT 1023 EDT ON 6/28/2016 FROM ART TUCKER TO MARK ABRAMOVITZ * * *

The following report was received from the Texas Department of State Health Services via email: On June 23, 2016, the licensee provided updated information to the Agency (Texas Department of Health Services). This information stated the activity of the radionuclide was 62 and 56 millicuries instead of the 15 millicuries previously reported. Notified the R4DO (Hipschman), NMSS Events Resource (via e-mail) and Mexico (via e-mail). 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

The following was received from the State of Texas via email: On May 4, 2015, licensee's Radiation Safety Officer (RSO) reported to the Agency (Texas Department of State Health Services) that he had been notified today that on Thursday, April 30, 2015, a physician had ruptured an I-125 seed during removal from a patient. The seed was used for localization in a breast treatment procedure. The seed activity was 357 microCuries at the time of treatment on 4/30/15. The seed was identified as leaking after removal and in a container in the pathology department. The physician had screened the patient with a probe in the tissue/lesion and no radioactivity was found. No overexposure to the patient or doctor had occurred. The RSO stated he was preparing a full detailed report. Further information will be provided in accordance with SA300 guidelines. Texas Incident # I-9310 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.

• * * RETRACTION AT 1347 EDT ON 05/20/15 FROM KAREN BLANCHARD TO S. SANDIN VIA EMAIL * * *

This report is retracted based on the following: More complete information was obtained from the licensee. The seed covering was damaged by the physician during excision of tissue from patient. The patient was thoroughly checked following the excision (standard procedure) and there was no radiation detected. There was radioactivity detected in the excised tissue by pathology after seed was removed from the tissue. The licensee identified and remediated all contamination and managed processing of tissue to prevent further contamination. No aspect of the event met any reporting criteria. It has been determined this was not a reportable event. Notified R4DO (Taylor) and NMSS Events Notification via email.