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 Entered dateEvent description
ENS 4407920 March 2008 07:37:00

A representative of Baker Atlas, a fishing and well-logging company, reported that a F-250 pick-up truck was stolen this morning between midnight and 5:30 a.m. central time. Contained in the truck were 4 neutron generators with a source strength of less than 1 curie each and one well logging source with a source strength of 100 milliCuries of Cs-137. The State of Texas is following up on the report with more details to follow.

  • * * UPDATE AT 1435 EDT ON 03/20/08 FROM LATISCHA HANSON TO S. SANDIN * * *

The following additional details were provided by the State of Texas via email: Event Description: On March 20, 2008, at 6:25 a.m., the agency received a telephone call from the licensee, reporting the theft of one of the company's vehicles, a Ford F-250 pick-up truck (licensee will find license plate number and submit later) from a hotel in Pharr, Texas, which had four neutron generators and one logging tool that contained a 100 milliCuries (mCi) radioactive material (RAM) stored on the truck. The licensee reported that the crew was from their Pearland, Texas site. The licensee stated the vehicle containing the sources was stolen from the LaQuinta hotel in Pharr, Texas between the hours of 12:30 and 5:00 A.M. on Thursday, March 20, 2008. The licensee immediately contacted the Pharr Police Department and filed a theft report. The licensee further reported that the initial police investigation shows that the vehicle has not crossed into Mexico. The licensee submitted the following information regarding the stolen equipment: A. The Cesium source is a Gulf Nuclear CS-2 with an original capsule number of CS2-985. This source was shipped with a tracking ID of S3H01 12. The activity is 3.7 GBq (100 mCi). B. The Pulsed Neutron Generators (SSDR, along with a section of our Transport Manual showing the container that the tools are carried in and a drawing of the tool section sent to Incident Investigation Program (IIP)). The tools in question are: 1. Generator 370457 mounted in tool 8283PA-10041239 and containing tube 327. 2. Generator 370453 mounted in tool 8283PA-370403 and containing tube 321. 3. Generator 189707 mounted in tool 8283PA-190149 and containing tube 340. 4. Generator 189496 mounted in tool 8283PA-370249 and containing tube 271. Each of these generators contains less than 37 GBq of H-3. The licensee stated that their company uses a tracking number system in place of the traditional model/serial numbers. The licensee will try to research the traditional numbers to submit later. Texas Incident #: I-8496 Notified R4DO (Whitten) and FSME (Burgess).

  • * * UPDATE AT 1800 EDT ON 04/01/08 FROM LATISCHA HANSON TO S. SANDIN * * *

The truck was recovered early morning on Saturday, March 30, 2008 just south of Falfurrias, TX. The search is on-going for the missing rad material. Notified R4DO (Lantz) and FSME (White).

  • * * UPDATE AT 1923 EDT ON 04/08/08 FROM LATISCHA HANSON TO J. KNOKE * * *

The State provided the following information via email: On April 6, 2008, (licensee) received a call from (their) security consultant stating that the Mission Texas Police Department (PD) had contacted him that a radioactive source had been located near the intersection of Bensen Palms Road and Orange Grove Drive. At 1:08 PM, Officer (delete) of the Mission PD contacted (licensee) and confirmed that the device appeared to be our stolen Cesium Source and that the padlock was intact. (Licensee) dispatched our local District Manager (DM) and an engineer to the location to take possession of the source and transport it to our storage location in Edinburg, Texas. The local DM confirmed that the source was intact and conducted an area survey to ascertain that no contamination had occurred. The local DM and the engineer will drive the area around the recovery, but at this time there is no sign of the missing Neutron Generators and associated tools. Notified R4DO (Deese), FSME (Kock), ILTAB via email. THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Less than Cat 3 event. Note: the value assigned by device type "Category 3" is different than the calculated value "Less than Cat 3

ENS 4415018 April 2008 11:50:00

The State provided the following information via email: On April 17, 2008, the agency received written notification from the Radiation Safety Officer (RSO), reporting that during their routine inventory check they, accompanied by two of their health physics consultants, found the one tritium (H-3) exit signs in a non-public receiving area in their Cypress, Texas store, had a missing face plate, frame and label, red 'EXIT' cover and several H-3 tubes. The RSO reported that the remaining H-3 tubes were intact. The RSO reported that they conducted informal interviews with store managers and associates that revealed no additional information as to the date or circumstances of the damage to the sign. The RSO and their consultants stated that because available information does not suggest that the H-3 exit sign (TES) was recently damaged, Wal-Mart believes that no significant contamination currently exists at the site. Additionally, he stated that Wal-Mart reached this conclusion in consultation with consultant Certified Health Physicists (CHPs). The RSO stated that their long term corrective actions included: implementing protocols, which have been communicated to employees, for the proper handling of TES to ensure public health and safety and the protection of its employees. They report that they are in the process of inventorying all of the TES at its sites across the country to re-establish the accuracy of its records and to track the current locations of the TES, with the intent of ensuring that all TES are accounted for and handled properly. The RSO stated that the damaged TES will be packaged for shipment according to protocols established by their consultants and consistent with Nuclear Regulatory Commission (NRC) guidelines. Wal-Mart anticipates shipping the remnants of the damaged TES to a specific licensee or arranging for a waste broker to ship the TES to a specific licensee authorized to receive it within thirty-days of their report to the agency, which was dated April 10, 2008. Texas report I-8507

  • * * UPDATE PROVIDED BY LATISCHA HANSON VIA E-MAIL TO JASON KOZAL ON 04/23/08 AT 1449 * * *

On 04/22/08: The agency received written notifications each dated April 17, 2008 that three more exit signs were found damaged at the following locations: 1) 4700 East Palm Valley Blvd., Round Rock, Texas 78665-2580; Store # 5480

   - Damaged exit sign discovered on 03/19/08
   - approximately 11.5 Ci; Serial # unknown
   - one damaged exit sign with the tubes in the letter "T" broken.

2) 620 S IH-35, Georgetown, Texas 78628-4157; Store # 1303

   - Damaged exit sign discovered on 03/18/08
   - 20 Ci; Serial #289930
   - one damaged exit sign uninstalled and stored in the manager's office, missing it's face plate, it's red "EXIT" cover and all H-3 tubes.

3) 1030 Norwood Park Blvd., Austin, Texas 78753-6600; Store # 1185

   - Damaged exit sign discovered on 03/19/08
   - 20.0 Ci; Serial #274828
   - one damaged exit sign with broken tubes, installed in the non-public receiving section of the store.

Notified R4DO (Cain), FSME EO (Hsueh).

  • * * UPDATE PROVIDED BY ART TUCKER TO JASON KOZAL ON 4/30/08 AT 1029 * * *

The State provided the following information via email: The State of Texas received notification of nine additional exit signs which had either damaged (4) or missing (5) vials containing tritium (H-3.) The RSO for Wal-Mart stated that the information gather in the inspections conducted throughout the United States was being entered into a database and that they would supply the State of Texas with the results of their inspections conducted in Texas as soon as it was available. No estimate of the number of vials involved or the total activity released has been determined as of today's date. He also stated that he had been in contact with the NRC. Notified R4DO (Pick), FSME (Burgess). 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

ENS 440396 March 2008 12:30:00
ENS 4399319 February 2008 12:22:00

The following report was received via email from the State of Texas: At 8:04 p.m., Radiation Control (RC) was contacted through the 24-hour Radiological Emergency Assistance telephone number by San Jacinto Emergency Management, reporting a car accident in San Jacinto County, on Highway 59, north of Houston, where a company was transporting a radioactive camera which was thrown from the truck onto the roadside. The Emergency Management representative reported that there was no leakage from the camera and that the driver sustained minor injuries. They did not have the company's name or any additional information on the radioactive source and was following instructions to make the initial notification to the State. The Emergency Management representative said they would call back with additional information.

The Emergency Management representative called back and relayed the following information:

Company/Licensee: National Inspection Services - out of Crowley, TX The Emergency Management representative reported that the Cleveland Haz-Mat team was handling the incident, but did not have any contact information for them.

RC placed a call to the company contact, who informed RC that he was enroute from Sulphur, LA and would be on-site in 2 hours. He gave me the name and the telephone number of the Haz-Mat chief on-site. He also said another company supervisor was enroute from Lafayette, LA and would be there ~1 hour.

RC then called the Haz-Mat chief on-site, who reported that they surveyed with a Victoreen 6A series survey meter on the x100, x10 and x1 scales and got no readings of any radiation leakage. He said the camera was intact but out of its transport container. He informed RC that they were going to transport it back to the station. RC asked him for the manufacturer's information on the camera. The chief said he had it an ice cooler, with styrofoam overpack in the back of his truck and to call him back ~ 3 minutes for the information.

Meanwhile RC called the company representative from Lafayette, had the camera information:

Mfg.: SPEC 150 Ir-192 camera with ~ 30 Ci source.

He said that a Level II Radiographer was also in the company vehicle and was on the accident scene with the chief and could answer any questions. He also said the Texas Radiation Safety Officer (RSO) was contacted and would get with RC. He said the truck was a complete loss, the darkroom broke apart off of the truck and the camera was thrown out of the darkroom. He said the Level II Radiographer followed their O&E procedures for handling the recovery and securing of the camera. He said the camera would be picked up tonight by the company representative from Sulphur and would be sent off to SPEC in the morning for leak testing. I reminded him of the written notification as a follow-up to the telephone notification. He did not know off-hand their Texas Radioactive Materials License (RAML) number.

RC called the chief back right away, whose information concurred with the company representative's. RC then asked to speak with the Radiographer, who confirmed that he oversaw the camera recovery, examination and radiation surveying and concurred that the camera was neither damaged nor leaking. RC told him and the chief that in keeping with Increased Controls (IC), to have the Radiographer travel with the camera when it is transported back to the fire station, so that visual control of the camera is maintained by the licensee. RC also asked that the company representative from Sulphur, LA contact RC when they picked up the camera and the employee.

RC placed a call back to the other company representative from Lafayette and relayed the same information to him. He agreed to call me back as soon as he had secured them both.

RC followed up with a resolution summation call to San Jacinto Emergency Management.

I will await the camera secured-confirmation call from Joe. At 11:04 p.m. (CST) RC received the telephone call from the Haz-Mat employee that the camera and company employee were both picked up.

02/19/08, camera verification information from licensee @ 9:49 a.m.: Mfg: SPEC Model: 150 Serial No.: 875 or 820 Source: Ir-192 25 Ci Mfg.: SPEC Serial No.: OH2913 Last leak test: 01/31/08 Texas Incident #: I-8484

ENS 438223 December 2007 23:13:00

The licensee's radiography team left the temporary jobsite with their SPEC 150 radiography camera on the tailgate. The camera contained a 24 Curie Ir-192 source. The licensee drove approximately 15 miles down the road prior to remembering the gauge was on the tailgate. It was then noticed that the camera was no longer in the truck. The licensee team is retracing their route in search of the camera and will be contacting the Tarrant County Sheriff's Department to aid in the search. The licensee is not sure if the camera had been secured properly prior to driving down the highway. The route taken was from Tinsley Lane to North Business 287 in Saginaw, TX towards Justin, TX in Tarrant County. Notified NORTHCOM and Mexico via email. Texas Report TX-07-43822

      • UPDATE FROM TEXAS DEPARTMENT OF HEALTH (JISHA) TO HOWIE CROUCH AT 0743 ON 12/04/07 ***

The SPEC 150 radiography camera was recovered at 0633 CST. A member of the public found the camera and placed it in the back of his private vehicle. Upon hearing about the lost source on the local news this morning, the citizen turned the camera over to the Fort Worth Fire Department. The camera appears intact and undamaged. Texas Department of Health is responding to the fire department to conduct a survey and inspection of the camera. No overexposures are expected. Notified DHS (Haselton), DOE (Parsons), FEMA (Burckart), USDA (Watts), HHS (Garcia), EPA (Johnson), Mexico (via email), NORTHCOM (via email), R4DO (Hay), FSME EO (Burgess) and ILTAB (Sandler). 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.

ENS 4373018 October 2007 14:53:00

The State provided the following information via email: On October 18, 2007, the agency was contacted at 12:49 p.m. by their emergency answering service, reporting that a licensee had lost a gauge in Houston and was requesting Incident Investigation Program (IIP) to call them back to assist them with (the lost gauge). IIP called the licensee back and talked with (DELETED), Site RSO for their LaPorte, TX location. (RSO) reported that his technician was driving down the highway in Houston and discovered that the gauge had fallen out of his truck around 12:15 -12:30 p.m. on 10/18/07. The RSO stated that the tailgate was up, but the gauge may not have been braced down. The technician immediately called the RSO, who drove down the highway and found pieces of the gauge, the handle, and the Cs-137 source. The RSO stated the Cs-137 source is intact. He remains on location with the agency's investigator. The agency's investigator has surveyed the area and the gauge pieces that were recovered with a NaI detector and was not able to locate the AmBe source. The gauge specifications are: Mfg: Troxler Model 3430, Serial #: 29328, Last Leak test: 10/11/07 Source Information: 1) Cs-137 Serial #: 750-2544; 8 mCi 2) AmBe Serial #: 47-26370; 40 mCi. The source is double-encapsulated in stainless steel, with dimensions of: .4 in.x.3 in. and is less than 1/2 in. long and 1/4 in. in diameter.

Mfg states that the chance of the source encapsulation being broken and breached is remote. The agency has notified local law enforcement (LLE) to shut down the 3-lane highway (so that) safe surveying for the AmBe source can be accomplished. The agency has asked LLE to contact and coordinate with the local HAZMAT team. IIP will continue to investigate and assist with locating the lost AmBe source. Additionally, the licensee was given contact information for two consultants to assist with this incident and location of the lost source. Incident Investigations will continue to update this incident as current information is received. Disposition/Action Taken: 1) Report to NRC and NMED, 2) Contacted local law enforcement (LLE) and local HAZMAT. Texas Incident Number: I - 8449, Event Report: TX-07-43606

  • * * UPDATE FROM ART TUCKER TO JOE O'HARA AT 2125 ON 10/18/07 * * *

The state along with DOD personnel performed a search of highway 225 for the missing source. However, the search was unsuccessful. The highway has been reopened, and the state will meet tomorrow to discuss further follow-up actions. Notified R4DO(Proulx), FSME EO(Tschiltz), ILTAB(e-mail), and Mexico(fax). 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.

ENS 4360629 August 2007 13:42:00

On 08/29/07 at 10:55 a.m., the agency received a call from (the) RSO for the licensee, reporting a High Dose Remote Afterloader (HDR) misadministration that occurred on 08/22/07. The RSO reports that today, 08/29/07, it was discovered that a patient received one HDR treatment on 08/22/07, with 2500 cGy being delivered instead of the planned dose of 500 cGy per fraction for 5 fractions. The RSO reports that the unit was a Varian VariSource loaded with Ir-192. The RSO will include model & serial numbers for the unit & source in his 15-day report to the agency. The misadministration was discovered today after an independent physicist's review of the treatment plan. The RSO stated the patient denies any symptoms and was being seen by the Radiation Oncologist. He stated the patient's family and referring physician were also notified. Texas Incident No.: I-8439 Texas Event Report No.: TX-07-43606

  • * * UPDATED INFORMATION ON 08/31/07 VIA EMAIL FROM LATISCHA HANSON TO MACKINNON * * *

Telephone call placed to (deleted), Ph.D., L.M.P., RSO for the licensee for updated information from 08/29/07 after the patient was seen by the Radiation Oncologist: Deleted reports that the patient was seen by the Radiation Oncologist & is being observed in a 'wait & watch' following. (Deleted) reported that the patient's Pulmonologist has taken over & (deleted) stated the Pulmonologist said 'We may have gotten lucky & even cured the guy.' The patient is still reported as doing well, with no adverse side effects being reported, as stated by (deleted). (Deleted) stated a CT was performed prior to the planned second treatment on 08/29/07, with no adverse effects viewed on the CT scan.

                                         " ***ADDITIONAL NOTE TO ORIGINAL REPORTED INFORMATION***

Deleted reported on 08/29/07 that this HDR misadministration occurred as a result of the incorrect isodose line being chosen & entered into the treatment planning system. (Deleted) reported that the treatment planning system then normalized the calculations to this incorrect isodose line & the resulting treatment dose was what was delivered on the first treatment day. (Deleted) stated the Oncologist signed & approved this treatment plan & that (deleted) himself, did a second calculation check on the treatment plan. The calculation error was caught by an independent physicist PRIOR to the planned second treatment.

Incident Investigations will continue to update this incident as current information is received. Incident Investigation personnel plan to conduct an onsite investigation upon receipt and review of the required 15-day report from the licensee. FSME EO (Sandra Wastler) & R4DO (R. Nease) notified.

  • * *UPDATE ON 09/04/07 FROM LATISCHA HANSON VIA EMAIL TO MACKINNON * * *

On 08/29/07 at 10:55 a.m., the agency received a call from (delete), L.M.P., RSO for the licensee, reporting a High Dose Remote Afterloader (HDR) misadministration that occurred on 08/22/07. The RSO reports that today, 08/29/07, it was discovered that a patient received one HDR treatment on 08/22/07, with 2500 cGy being delivered instead of the planned dose of 500 cGy per fraction for 5 fractions. The RSO reports that the unit was a Varian VariSource loaded with Ir-192. The RSO will include model & serial numbers for the unit & source in his 15-day report to the agency. The misadministration was discovered today after an independent physicist's review of the treatment plan. The RSO stated the patient denies any symptoms & was being seen by the Radiation Oncologist. He stated the patient's family & referring physician were also notified. R4DO (Pruett) & FSME (Jack Davis) notified. 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 4350719 July 2007 17:08:00

EVENT: Radioactive Material (RAM) found - sealed License Number: "Unlicensed The agency received a call at 2:15 p.m. today (7/19/07) from DSHS Food & Drug Inspector, (DELETED) inquiring about four radiation devices found with 1994 inspection stickers on each of them. She said there appears to be some concern as of what company owns them and the facility they are located at. She gave me three names of possible companies, or owners: I Q Distributors Diversified Materials Services Diversified Medical Services Inc. The facility is located at: 2400 Central Parkway, Suite LP in Houston, Texas 77092. She is currently on location. Agency Action Taken: Region 6 RAM Inspector to go to the facility as soon as possible to conduct incident investigation & identify sources. Texas Incident Number: I-8428

* * * RETRACTION FROM L. HANSON TO P. SNYDER AT 1657 ON 9/4/07 * * * 

The NRC received the following information from the Agreement State of Texas via facsimile: On 08/23/07, the Agency received a telephone call from the individual who received the gauges from Kellogg Brown & Root, Inc. (KBR) & was given the following information: The individual stated that on 03/03/06, he purchased a portion of the building at 2400 Central Parkway, Ste. L, Houston, Texas. The purchaser reported to the Agency that he was not aware that the portion of the building he just bought, Suite L, contained the alloy analyzers found by DSHS inspectors until he was recently contacted by the agency. He stated he thought he bought lab equipment only & was unaware that the building purchase included the alloy analyzers. The other suite, Suite P, is not owned by him & overseen by the initial individual contacted at the site by the agency's inspectors. He is not sure why this individual did not make the suite distinction with the inspectors nor contact him to let him know the building was being inspected. He contacted the agency's general licensing acknowledgement (GLA) division & was given the following information: These devices with Fe-55 and Cd-109 sources and no longer issued a GLA so anyone can possess these devices if transferred by manufacturer/distributor. A transfer is allowed if the devices are transferred in their physical location, which occurred when he bought the building. Additionally, the agency received documentation from the manufacturer that they removed the RAM sources from the two empty analyzers & shipped the analyzers back to KBR in 1997. The two analyzers which had very low-strength RAM sources were transferred in accordance with the above stated allowance. The purchaser asked if the agency could give him information on how he could dispose of the analyzers. The agency responded by forwarding information to the purchaser for possible contacts who could assist him with disposal. BASED ON THE ABOVE INFORMATION, THE AGENCY IS REQUESTING A RETRACTION OF THIS INCIDENT, SINCE IT IS NOW DEEMED NON-REPORTABLE. Notified R4DO (T. Pruett) and FSME (J. Davis). 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

ENS 4350619 July 2007 14:16:00

On 07/18/07 at 3:50 pm, the agency received a telephone call from (deleted), the Chief Tech for the licensee, reporting the misadministration of patient involving Thallous Chloride. The nuclear medicine tech reported that a patient was injected twice with a total of 4mCi of Thallous Chloride. The licensee reported that the patient was informed the same day of the misadministration. Licensee was informed that the 30-day report is due 08/17/07. Agency Action Taken: The licensee will submit the required written report within 30-days as per 25 Texas Administrative Code (TAC) 289.202(xx). Texas Incident number: I-8427

* * * UPDATE PROVIDED BY CINDY FLANNERY TO JEFF ROTTON AT 0741 ON 07/24/07 * * *

This event (EN43506) has been reviewed and determined to NOT be a reportable medical event.

ENS 4330213 April 2007 18:15:00The RSO called (1625 CDT on 4/13/07) to report that during their quarterly inventory check, the facility discovered that (3) tritium exit signs were lost: Mfg: BetaLux Model 171-20-R-U-WH-D-RD, Serial Numbers: 255-381; 255-319; 255-399, Activity Source: 20 Ci each. Root Cause: The RSO (and) Incident Review board believe the exits signs were inadvertently knocked down (and) thrown away, so that the person responsible would not be found out (and) held accountable. TI runs a 24 hour-7day operation, so the RSO explains it is very difficult to find the culprit(s). Committee corrective action: Current (and) replacement signs will be attached with a secondary tether so that if the signs are knocked down, they will not fall down, but dangle until refastening is performed. Texas Incident Number: I-8403. 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source.
ENS 4330718 April 2007 13:05:00On March 13, 2007, the Agency was notified by the licensee that their source pool conductivity had exceeded 100 microsiemens per centimeter (uS/cm). The facility had completed a source replacement the week of February 21, 2007 and had regenerated their ion exchange resin on March 9, 2007. On March 11, 2007, the water conductivity was found to be 269.1 uS/cm. The licensee conducted an investigation and found that the system used to control the regeneration of their ion exchange resins, had failed to operate properly due to a power outage. The purification resins were replaced and the conductivity was reported to be 69.34 uS/cm on March 30, 2007 and 1 uS/cm on April 4, 2007. The licensee has upgraded the control system and is measuring conductivity twice a day to prevent a reoccurrence. Texas report number - I - 8402
ENS 430849 January 2007 18:17:00The agency (Texas Department of State Health Services (DSHS)) returned a telephone call at 5 p.m. (on 01/09/07) to the licensee, in regards to a voicemail the licensee's RSO left on another program's telephone. The personnel answering the telephone at the facility stated the RSO had just left for the day & gave (the state) partial information that the facility had received the personnel monitoring report for 11/10/06-12/06/06 that showed a radiographer's dose to be 697,408 (mR) -Deep dose. The employee stated that the monitoring processing company was going to repeat the tests again to confirm the dose. The licensee was waiting to hear from DSHS/Radiation Control (RC) on 1/09/07, to decide what to do. They were not sure if they should do blood work, etc. DSHS/RC advised the employee to 1) Have the RSO call DSHS/RC Incident Investigation (IIP) personnel first thing in the morning on 1/10/07; 2) Have the RSO perform an inquiry with the radiographer to assess the events during the monitoring period in question; 3) Have the RSO look at personnel monitoring records for co-workers on the same job(s) as the radiographer under review to compare their dosage during this time period; 4) Have RSO check utilization logs during this period to assess what specific equipment was used & the job details; 5) DSHS/RC requested a fax copy of the personnel monitoring report (Deleted). The employee agreed to comply. DSHS/RC will follow-up first thing 1/10/07 with the licensee's RSO to obtain complete information. Additional clarification/corrective information may be submitted by DSHS/RC after interview with licensee's RSO. " Texas Incident number: I-8383
ENS 4264816 June 2006 11:19:00

The State provided the following information via email: Radiation Control received a call at 9:15 am from (name deleted) the Radiation Safety Officer (RSO) for QC Testing Laboratories, Inc., 10810 Northwest Freeway, Houston, TX, 77092, License # L04750-003, reporting that a technician was at a jobsite in the Houston suburb of Brookshire, when the technician noticed that the chain and lock bracing a moisture density gauge was cut, and the gauge and its case were subsequently stolen around 9:00 am, 6/16/06. The Gauge Information is as follows: Manufacturer - Troxler; Model 3430; Serial # 367007. Source information: Cs-137, 8 millicuries, Serial # 751-796; Am-241Be, 40 millicuries, Serial # 78-1538. The last leak test was performed April 26, 2006. Local police were immediately notified, who in turn have contacted local FBI. The licensee will fax a copy of the police report to Radiation Control as soon as available. Radiation Control was contacted at 10:00 am by the Chief of Police, Brookshire, to confirm the licensee had contacted the agency and to received additional information on the stolen equipment. An email with the device information and a copy of this report was sent to the police chief (email address deleted). Radiation Control is continuing to investigate & will transmit any updated information as soon as it is received. Texas Incident # I -8347.

  • * * UPDATE PROVIDED BY LATISCHA HANSON TO JEFF ROTTON AT 1833 EST ON 11/15/06 * * *

The State provided the following information via email: At 1145 hrs. CST, the TX state Agency was notified by (name Deleted), the Program Director for Alabama that a Troxler moisture density gauge was being sold on E-Bay. Their staff had been surveying the site in hopes of finding a recently stolen gauge in Alabama and the seller was identified as (name Deleted). At 1230 hrs. TX staffs were dispatched to the pawn shop, where initially, the representative failed to cooperate and show the inspectors the device or even reveal the storage location in a local warehouse. As an Impoundment Order was being drafted and local law enforcement authorities were being notified, the (name Deleted) employee consented to having the device delivered to the shop for identification and confiscation if it contained radioactive material. The device and associated paperwork were transported back to Austin for investigation as to who the owner is and what incident is associated with the recovered gauge. (At 1500 CST), the gauge was found by serial #, to belong QC Laboratories, Inc., L04750, TX Incident #I-8347/TX-042648. The RSO has been contacted and agreed to make arrangements with DSHS/Radiation Control for pickup; pick up details to be determined during discussion between both parties on 11/16/06. Notified R4DO (Johnson), NMSS EO (Camper), ILTAB (via email) and Mexico (via fax). 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.

ENS 4258116 May 2006 22:49:00

The licensee while transporting a Campbell Moisture Density Gauge S/N MC1391 from one jobsite to another in El Paso, TX, discovered upon arrival that the tailgate of the truck was down and the transport case with gauge were missing. The loss occurred within a sixteen (16) mile radius of the intersection of Hawkins Blvd. and Montana Ave. The licensee acknowledged to the TX Department of Health representative that the instrument had not been properly secured prior to transport. The gauge contains two (2) sources, i.e., 50 millicuries Am-241/Be and 10 millicuries Cs-137. The licensee informed local law enforcement and the TX Department of Health. TX Incident No. I-8338

        • UPDATE ON 5/17/06 AT 2250 EDT VIA E-MAIL FROM LATISCHA HANSON TO SANDIN ****

Incident # correction: It should be I-8337.

        • UPDATE ON 5/29/06 AT 2057 EDT FROM LATISCHA HANSON TO KNOKE ****

The licensee (RSO) contacted the TX Department of Health representative to indicate that a trucker who is presently in Chicago, IL., found the instrument. The RSO requested the trucker FedEx the gauge back to the licensee. When the State tried the trucker's phone number they received a message that the number is disconnected. No other identification concerning the trucker was available. Contacted NMSS (Janosko) and R4DO (Cain). Emailed ILTAB and Mexico.

  • * * UPDATE PROVIDED FROM LATISCHA HANSON TO JEFF ROTTON AT 2110 EST ON 11/29/07 * * *

The State provided the following information via email: On November 24, 2007 at 3:08 pm CST, the Incident Investigation Program (IIP) was contacted by the local El Paso, Texas FBI during the State holiday office closure, that the (moisture density) gauge had been recovered by the local police department and retained for evidence. The individual had made a call to the local fire department reporting that his family may have been exposed to radiation from a piece of equipment on his property. The local fire department in turn contacted the local police department, who discovered it was the reported stolen gauge in May 2006. The local police department contacted the local FBI. The individual was questioned thoroughly by the FBI and finally admitted to having picked up the gauge over a year ago. The FBI asked if it was ok to return the gauge to the owner; IIP gave the ok. The FBI will contact the licensee owner to retrieve the gauge from them. The FBI agent reported the gauge was intact. It is still being decided if the individual will be prosecuted. On November 27, 2007 at 3:38 pm CST, IIP received a telephone call from the licensee asking if they could take possession of the gauge and asked if they had any more reporting requirements. They were given permission to take possession, asked to submit in writing to the licensing program that the gauge was found and to give information that gauge was checked and found to be intact. The licensee agreed. Notified R4DO(Pick), FSME EO (Rathbun), ILTAB (via email), and Mexico (via Fax). 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 injured someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

ENS 423166 February 2006 15:34:00The State provided the following information via facsimile: On December 26, 2005 morning, the licensee discovered that their facility was burglarized sometime between 12/24 & 12/25/05. The licensee immediately contacted the Houston Police Department (HPD) to process a report. After conducting a quick tour of the facility with the police, the licensee noticed that some test equipment and a combination safe were taken from the test room. The safe contained (2) Cs-137 calibration/check sources @ 200 microcuries each. The safe was locked and was posted with a 'Caution Radioactive Material' sign. The Houston police were given all required information to conduct an investigation. The licensee also contacted their consultant, Bruce Bristow of Radiation Consultants, Inc. regarding the incident and were advised to purchase (2) replacement sources from the same manufacturer with the same source strength. The Texas Incident Number is I-8296. 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.
ENS 422404 January 2006 15:17:00

The State provided the following information via email: The (Texas) Department of State Health Services (DSHS), Radiation Control received written notification from (Name Deleted), Texas Regional RSO for IRISNDT, Inc. that one of its previous employee's received exposure in excess of 5 Rem annual dose. The RSO reports that while doing an update of radiation dose reports for all licensees' Texas employees, the Texas Regional RSO noted that a past employer exposure history was not recorded for a former employee (the radiographer) of the licensee. The RSO reviewed the personnel files for the individual and could not find a past exposure history from the record from the radiographer's previous employer. The Texas RSO contacted the Corporate RSO to see if he had a record for the individual. The Corporate RSO found an exposure history record and faxed it to the Texas RSO. The previous employer's record, H&G Inspection, (address deleted) reflected a dose of 3.918 Rem in the first 6.5 months of employment. The doses were compiled with IRISNDT's records and it was immediately noted that the radiographer had an accumulated dose in excess of 5 Rem. The Texas RSO called the former employee to notify him of the overexposure that same day of record discovery. The former employee stated that he thought the dose he had been assigned was not correct and that's why he did not inform the Texas RSO. It was determined through discussions with the radiographer that the radiographer has not worked since November 2005 and was informed that he cannot work in the industry until he talks to the DSHS. IRISNDT, Inc. stated they failed to check previous records and the radiographer failed to report (previous dose) to (IRISNDT). In the future IRISNDT, Inc. will provide a form for potential employees to complete pre-hire for dose records to be reviewed and the safety program administrator has been assigned the responsibility to call 2 times per week to follow-up on previous employer dose histories for new hires. Texas Incident No: I-8287

  • * * UPDATE FROM THE STATE OF TEXAS (E-MAIL) TO HUFFMAN AT 1200 ON 2/6/06 * * *

The final Texas Department of State Health Services Radiation Branch report on this incident noted that the total annual expose received by the individual involved was 5.713 Rem. The exposure breakdown was 3.918 Rem for individual's previous employer and 1.795 Rem while the individual worked at IRISNDT. The R4DO (Nease) and NMSS (Morell) were notified.

ENS 4216723 November 2005 14:39:00The State reported that a licensee, Kooney X-Ray Inc., shipped a radiography camera (Model #150; S/N 197) to QSA Global in Baton Rouge, LA, for replacement of the iridium-192 camera source. When the camera arrived and was inspected at QSA Global, low-level radioactive contamination was found on the camera. A wipe test (swipe area not specified) revealed a contamination level of 0.0059 microcuries. The acceptance limit for QSA Global is 0.0050 microcuries. QSA Global believes that the contamination is from depleted uranium shielding in the camera S-tube and not from the currently installed iridium-192 source. Kooney X-ray has requested that QSA Global return the camera. Kooney plans to have the camera S-tube repaired as necessary. The State reported that the contamination was confined to the camera and this event did not result in any personnel or uncontrolled contamination on any other items. Texas Report Number 8278
ENS 4214115 November 2005 12:00:00

The State provided the following information via email: The State of Texas received a call from the Radiation Safety Officer for Terra-Mar Inc. on Tuesday, November 15, 2005, reporting the theft of a moisture/density gauge, Troxler Model # 3430, Serial # 32220, with a 40 milliCurie AmBe source, Serial # 47-28552 and an 8 milliCurie Cs-137, Serial # 750-7360. The licensee went to the gauge storage area of the site on Monday, November 14, 2005, and discovered that the gauge was missing. The licensee checked with personnel to see if any one had removed it from the storage area. When no one acknowledged removing the gauge, the licensee contacted Texas Department of State Health Services (DSHS), Dallas-Ft Worth Department of Public Safety, and the Irving Police Department that the gauge was possibly stolen. The licensee will send in the police report and a written statement to DSHS. The last leak test performed on the missing gauge was performed on July 9, 2005. Texas Report Number: I-8277

  • * * UPDATE FROM S. SIMMONS TO J. KNOKE AT 13:28 EST ON 12/12/05.

The licensee provided more detail surrounding the missing Troxler gauges and added security measures for the storage area of other gauges. Contact the Headquarters Operations Officer for further information. The incident report No. from DFW Airport DPS is 050-5143. The DFW DPS is investigating the apparent theft and has assigned a detective to the case. A copy of the police report was sent to DSHS. On November 17, 2005, licensee installed an additional keyed padlock on the nuclear storage doors and placed a heavy duty chain and lock through the case handles of the remaining gauges. The licensee has also changed the combination code to the entry door of the building. Only the site RSO and one authorized user have access to the building and gauge storage area. Notified R4DO (Johnson) and NMSS (Morell)

        • UPDATE ON 02/01/06 AT 1500 VIA E-MAIL FROM S. SIMMONS TO MACKINNON *****

On Monday, January 30, 2006, I received a call from the RSO for Terra-Mar US Labs, informing the agency that an employee of the company had found the stolen gauge. The gauge was recovered at "First Cash Pawn" located at Wisdom Camp Rd., Duncanville, TX. The agency immediately responded by dispatching an inspector to verify that the gauge was in fact the property of the licensee. Once accomplished, the licensee was notified to recover the property. The gauge is now in possession of the licensee. Law enforcement officials are investigating the possibility of criminal prosecution. Case Close. R4DO (Runyan), NMSS EO (Greg Morell), TAS (e-mail) & MEXICO (e-mail) notified. 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.

ENS 4209228 October 2005 17:50:00The licensee provided the following information via email: On 09/21/05 while preparing for Hurricane Rita, the owner's truck was stolen from in front of his office in Houston, Texas, 77087. Since his office is a trailer, the owner thought it best to put his Niton Alloy Analyzer (6 millicuries Cd-109 s/n U1238 NR5498) in his truck to bring home in case his office was destroyed by the hurricane. Houston law enforcement was notified as soon as owner discovered the truck missing. His truck was recovered 10/13/05, but the analyzer was not. Texas Incident No: I-8273 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.
ENS 419769 September 2005 12:07:00
ENS 4209128 October 2005 17:50:00The licensee provided the following information via email: The written prescribed dose for this treatment was 550 cGy with the plan of repeating another procedure one week afterwards for a total prescribed dose of 1100 cGy. This dose, to be given in 2 fractions, was to be delivered to the vaginal cavity using High Dose Rate (HDR) afterloader device. The first fractionation of 550 cGy was delivered incorrectly, approximately 4.5 cm anterior to the correct position. This resulted in the intended target area receiving 1451 cGy in one treatment. The medical physicist discovered the error in the brachytherapy vision software (planning system). When digitizing the calculation point of the coronal plane, the sagittal plane viewing plane was in an incorrect position that resulted in the calculation point being entered incorrectly. There was no other medical physicist to second check the plan at that time due to personnel shortage issues. The prescribing physician determined that the clinical effect of the dose is negligible and there is no impact to the patient's well being. Texas Incident number: I-8253 Event Report ID No: TX-05-41932
ENS 4193219 August 2005 16:20:00The State provided the following information via facsimile: The State received a telephone call from an RSO with The University of Texas Southwestern Medical Center (UTSWMC) at Dallas on August 16, 2005 at 4:00 p.m. to report a patient misadministration of a therapy dose at UTSWMC Moncrief Medical Center. The event occurred on August 15, 2005 around 4:00 pm. The patient was scheduled to receive 1100 centiGray in two fractions for cancer treatment. Each fraction was supposed to be 550 centiGray to the vaginal vault. The first dose was oriented interior 4 1/2 cm, i.e. too close. The true target point of the vaginal vault received a dose of 1451 centiGray. The second dose was not administered and the patient is not returning for further treatment. Source was an Ir-192 HDR (high dose rate) afterloader.
ENS 421081 November 2005 19:09:00The State provided the following information via email: (Licensee employee) called RSO to let him know that (a radiographer trainer) had 12.5 rem deep dose equivalent for Quarter 3 - July 1-31, 2005. On Wednesday, 8/10/05, (name deleted), RSO for Turner Industries called DSHS Radiation Control (RC) to report that (licensee employee) has informed him that (name deleted) radiographer trainer for his company, had a 12.5 rem deep dose equivalent reading for Quarter 3-July 1-31, 2005 monitoring period. (The radiographer trainer) wrote a statement to RC stating that he has worked as an x-ray radiographer for the last 6 years with Turner Industries, is very conscientious & checks his dosimeter often throughout the work day. He stated that he was closely supervised by the RSO for the monitoring period in question & did training for a new trainee. An on-site investigation was conducted by (name deleted), a RAM inspector for RC. (The RAM inspector) interviewed (the radiographer trainer) & (another employee) regarding this investigation. Both (the radiographer trainer and the other employee) felt that this was a result of an altercation (the radiographer trainer) had with a contract radiographer & felt that this was the result of a retaliation against (the radiographer trainer) for not allowing the contract radiographer to enter (the radiographer trainer's) shooting bay. (The radiographer trainer) went on vacation & from 6/27-07/5/05.The RSO & (the radiographer trainer) felt that the contract radiographer had access to (the radiographer trainer's) film badge & a radiography camera & could have easily carried out this retaliation without being noticed. The RC inspector reviewed past monitoring records for (the radiographer trainer) & found that his results were consistent with someone receiving 50-60 mrem /month & 500-650 mrem/year in this line of work. The inspector concluded that the overexposure appeared to be very suspicious & agreed that the overexposure be readjusted to reflect the normal monthly results for (the radiographer trainer). Additional Documents Supplied: Personnel monitoring records for the past year for (the radiographer trainer) were obtained & sent in to RC by the RAM inspector. The investigation determined that the dose appeared to be to the dosimeter only. No violation recommended. RC has issued a letter concurring with the licensee's investigation results & has sent a copy of this letter to DSHS RC. Texas Incident # I-8250
ENS 4183512 July 2005 14:49:00

The State provided the following information via email: Texas Radiation Control received a telephone call from (the licensee's RSO) . The RSO was contacted by Landauer regarding an exposure to a 'film badge' in excess of 1,000 (one thousand) rads. The badge was being worn by (name deleted). His exposure for the previous quarter was 350 millirem and for 2004 he received a total exposure of 290 Mr. The badge had been returned for evaluation with 4 other badges, which had no problems with excessive exposure. (The individual) only performed four tracer study jobs during the monitoring period and worked with a 34 mCi Ir-192 source. (The RSO) believes the badge was not worn. The licensee will be requesting the exposure be deleted. Texas Incident Investigation Program has contacted the licensee and requested additional information. A written report will be submitted within 30 days. The Event has received no media attention. Texas Incident No.: I - 8242

          • UPDATE ON 12/19/05 AT 1830 EST from Latischa M. Hanson (via e-mail) entered by MacKinnon ******

The licensee believes that the badge worn by (name deleted) during the first quarter of 2005 was intentionally exposed. The licensee states that the reported dose was in excess of the reporting capabilities of 1000 rad & concluded that the reported dose was not accurate. The licensee reported that (name deleted) terminated employee at the end of the first month of the quarterly monitoring period & that the employee worked with sealed sources during the first week & radiation work was performed afterward until time of termination. All jobs were short duration & neither the individual nor his single co-worker (supervisor) reported any unusual occurrences that would have resulted in a higher than normal dose. Based on the amount of the extremely high dose, the licensee concluded that the employee was not the recipient of 1000 rem (rad) dose & that the dose should be considered erroneous. Permanent dose record for (name deleted) reported by the licensee is as follows: 1st quarter 2005 - 0.349 rem; 2nd quarter 2005 - 0.100 rem. Licensee corrective action: "No corrective actions taken or planned since reported dose appears to be incorrect. The licensee has calculated a dose of 0.100 rem for the 2nd quarter & consequently assigned this to (name deleted) permanent personnel monitoring record. This is based on the individual's previous cumulative six-month period dose of 0.593 rem, which averages to (approx) 0.100 rem/month. R4DO (Shaffer) & NMSS EO (Essig) notified.