Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 41088 | 4 October 2004 15:16:00 | Shortly after noon on September 29, 2004, the Agency was notified by the Harris County Hazmat Team of a contaminated 55-gallon drum/Pig that had been 'spilled' on the side of the road by a Bank building several blocks from the city police station. (Deleted) and (deleted) noted the radiation markings and loaded the device into their Ford F150 truck, Texas License Plate # (Deleted). They transported the device to the Humble Police Department for assistance. Upon arrival, the Humble Police requested assistance from the Harris County Hazmat Team. Due to radiation markings on the container the Hazmat Team took readings on the container. The container was examined by two technicians dressed out in protective clothing and SCBA. When reported to this Agency there was some confusion in the initial readings obtained by the Hazmat Team. The reported level initially reported was 70 R/hr. Two Department of State Health Service's Radioactive material inspectors were dispatched to assist in the identification of the device. The bright yellow box with embossed lettering 'TROXLER' immediately identified the device as a Troxler moisture density gauge. The shipping container appeared to have a broken hinge. Initial confirmatory readings on the case indicated 1.5 millirem on the sides of the case and 9 millirem on the top of the package. Upon opening the case the gauge appeared to be intact. A brief search of the case located a calibration sheet from Texas Licensee (L02243-000) Component Sales and Services. The gauge was transported to the Regional Headquarters. After determining that the gauge was a Troxler 3430, Serial Number 23700, with two seal sources - Cs-137, Serial No 75-5786 and Am-241/Be, Serial No 47 19622. The gauge was initially reported by Troxler as belonging to the New Hampshire Department of Health. However, a later check with Component Sales and Services indicated that the gauge belonged to Texas Licensee - L05180-000, GeoScience Engineering and Testing, Inc. The Licensee was contacted and arrangements were made to pickup the gauge on September 30, 2004. During return of the gauge, the Licensee verbally reported that the gauge had been stolen while the gauge operator stopped at a Subway sandwich shop near Houston Intercontinental Airport. Texas Incident No. I-8170 |
| ENS 41123 | 15 October 2004 09:45:00 | The Licensee notified the Agency of a leaking source that was discovered on September 29, 2004 and confirmed by a second leak test on September 30, 2004. The source was for a Lagus Applied Technology, Inc. Model 101 AUTOTRAC Tracer Gas Monitor (SF6), Serial No. 177. The source was described as a Model 200-EC Electron Capture Detector, Serial No. 1271 with an activity of 300 millicuries, Tritium (3H) (October 3, 1998). The current activity is an estimated 214 millicuries. The leak test detected 18,178 dpm or 0.0082 microcuries of removable activity. The second leak test conducted September 30, 2004, confirmed the source was leaking with similar results. The gas monitor was taken out of service. After removing the SF6 compressed gas bottle, the monitor containing the leaking source was packaged for return to the manufacturer. The packaged source was shipped to the manufacturer on October 6, 2004. No violations were cited. Texas Incident No: I-8172 |
| ENS 40883 | 20 July 2004 13:13:00 | Moisture density gauge believed to be stolen during a stop at Lowes, Plano, Texas, to pickup parts. The operator claims that the chain or lock was cut. The chain and lock were not left behind. The gauge is a Troxler Model 3440, Serial No. 33851 with two sealed sources: Cs-137, 8 millicuries, Serial No. 750-9505 and Am-241/Be, 40 millicuries, Serial No. 47-3391. Both sources were last leak tested June 1, 2004. Driver left Lowes and proceeded to a convenience store across the parking lot for a carton of cigarettes. Upon returning to the truck the gauge was noted as missing. The vehicle was a company truck: white, Ford Ranger, #51, with green logos on both sides. Media attention: None known. Licensee is contemplating offering a reward for return of the gauge. The Plano Police Department was notified of this incident. Texas Incident No.: I-8144. |
| ENS 41189 | 10 November 2004 14:21:00 | On October 28, 2004, during a routine inspection of the Licensee, an Agency inspector discovered equipment discrepancies involving a Nucletron Selectron Model 106 Low Dose Rate (LDR) therapy device that indicated equipment failures which had not been reported to this Agency. A series of eight equipment failures interrupted patient treatments between May 16, 2004 and June 4, 2004. Radiation doses for the patients were not ascertained. No patient was injured. The Licensee failed to report the failures to this Agency within 24-hours and in writing within 7-days. The Licensee failed to forward these discrepancies to its Radiation Safety Committee (RSC) for resolution. The Licensee failed to prepare written directives for any patient treated on the LDR therapy device. No doses were listed in the treatment plan or in the patient's record. The Licensee indicated that corrective action would be cessation of operation of the LDR therapy device. Texas Incident No.: I-8179
The State provided the following information via email: A letter was sent to the licensee on 9/14/05 from Robert Free (State) informing the licensee that Condition 21 on their Texas License L01837, required them to report as follows: The licensee shall cease treatment of patients when any safety related system of a LDR device is found inoperative, to include the source drive mechanisms treatment timing system, safety interlocks and radiation field alarms. The licensee shall report to the Deputy Director, Emergency Response and Incident Investigation, any malfunction that requires the termination of patient treatments for more than 24 hours and submit a written report of the incident and corrective actions within seven calendar days. The response letter from the licensee dated 10/04/05, stated that there were actually 5 events affecting a total of patients; on 3 of these events there were 2 patients being treated simultaneously with the same LDR machine. In each case the attending physician was either on the premises or notified immediately. The physician either deemed the treatment received was sufficient or the treatments were rescheduled, some within 3 hours. It was discovered by the licensee that during the investigation of these events that severe thunderstorms preceded all LDR malfunctions. It was the conclusion that the LDR had functioned as designed by detecting the significant change in power & shut itself down. No misadministrations occurred. The manufacturer replaced the column, interface board, printer mechanism and power supply. The LDR has not been used in the past 12 months. In August 2005 the decision was made to take the LDR machine out of service. Notified R4DO (Johnson) and NMSS (Essig). |
| ENS 40430 | 7 January 2004 16:43:00 | Novoste Strontium-90 Intravascular brachytherapy (IVB) source (remote afterloader) was discovered missing on January 5, 2004. Source was last seen but not used on December 17, 2003. Reported by phone by RSO. Source is a small handlheld device - Manufacturer: Novoste, Model: BethCath, Serial No. 92607; Source train Serial No. ZB-520; Original Activity 55.62 millicuries; current activity (date of discovery) 54.64 millicuries; Calibration date: 04/11/2003; Last leak test 10/29/2003. Received at the hospital on November 4, 2003. Last used in a patient on December 5, 2003 (first and last use). Last seen on during a functional test on December 17, 2003 in the Fondren Building, Room F1099 (near cath lab) at the Licensee's main site 6565 Fannin Street, Houston, Texas. The source was not used that day. Two other sources of different activity and length remain in storage. The room and cath lab have been search 4 times by the Licensee's staff. Trash has been surveyed. Hospital staff has been notified of the missing equipment.. Texas Incident No.: I-8089. |
| ENS 40269 | 22 October 2003 17:07:00 | Event location: RLM Building Vault Room 2.306, J.J. Pickel Research Campus, The University of Texas at Austin, Austin, TX. Event description: While performing an exhaustive inventory of sources for possible recovery in the DOE Source Recovery Program it was determined by visual survey a 5 millicurie, Am-241, sealed-source was missing. The source was probably procured in the 1960's and has been indicated as in storage since the late 1980's. The last leak test that was currently available was dated 04/19/88. The source is suspected of being manufactured by the Monsanto Company and is listed as Serial No. M-376. No information on Model is available. The source is indicated as being sealed in 1-inch pipe. The RSO reports that the source has evidently been confused for years with another source that is indicated on storage records as CNS-1. However, he feels relatively sure that it is not the same source. Records indicated that the source was transferred to storage 11/27/84 and may have last been seen on 04/19/88. A visual and instrument survey of the last known storage facility did not locate the source. The RSO believes that the source may have been disposed of with Radium sources but there is no indication on shipment manifests. The previous RSO has been contacted and reportedly cannot recall details about the specific source. Transport vehicle description: Not applicable Media attention: None Texas Incident No.: I-8066 |