Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 56880 | 7 December 2023 14:36:00 | The following information was provided by the Texas Department of State Health Services (the Department) via email: On December 7, 2023, the Department was notified by a Texas licensee's radiation safety officer (RSO) that while testing an MDS Nordion, Model Eldorado 8, teletherapy unit, the 1,817 curie cobalt-60 source became stuck in the unshielded position. The RSO stated that the room was isolated and dose rates taken outside the room did not create an exposure risk to any individual. The RSO stated that a service contractor would likely repair the unit on December 9, 2023. Access to the room was posted to prevent inadvertent entry into the room. An update will be provided when the source is returned to the shielded position and then further information will be provided per SA-300. Texas Incident Number: I-10070 NMED Number: TX230056
On December 9, 2023, the Department was notified that the cobalt-60 source had been returned to the shielded position by the licensed servicing company. The technician who returned the source received around 0.3 millirem. The source activity is likely around 1,000 curies and not 1,817 curies, as originally reported. The Department will wait for the licensee and service company reports for information regarding the cause of the incident and report this to NMED per SA-300. Notified R4DO (Dixon) and NMSS Events Notification via email. |
| ENS 56761 | 27 September 2023 18:40:00 | The following information was provided by the Radiation Control Program Texas Department of State Health Services (the Department) via email: On September 27, 2023, the Department received a report of a source disconnect incident from a licensee that occurred on September 26, 2023, at around 1000 (CDT). The source is 63.6 curies of iridium-192 in an Industrial Nuclear Corporation (INC) IR-100 camera. The licensee could not give a narrative or a dose estimate for the trainee who was working the source. They did report that the drive cable was not broken, and it seems that this may be a misconnect. They were not able to provide a time estimate for the exposure to the trainee, but they were talking about minutes. They have taken the trainee to a medical facility for blood tests with no results yet. This Department recommended that they send bloodwork to (Radiation Emergency Assistance Center/Training Site) (REAC/TS) and provided contact information for REAC/TS. The Department has also asked that the licensee take daily pictures of the trainee's hands. His dosimetry badge has been sent in overnight for processing. The trainer was reportedly not close to the source and his dose was reported as not significant. An experienced consultant has been hired by the licensee and will begin work in the morning reconstructing what happened. A meeting with the Department is set up for 1100 (CDT) to discuss a dose estimate as well as get a narrative. The source retrieval was performed by the associate radiation safety officer and another individual. Licensee has reported that both are trained to retrieve sources. Each person received about 90 mR. An update will be provided to the (NRC) Headquarters Operations Center (HOC) tomorrow afternoon. Further information after that will be provided per SA-300. Texas Incident Number: I-10055 Texas NMED Number: TX230046
The following information was provided by the Radiation Control Program Texas Department of State Health Services (the Department) via email: On September 28, 2023, the Department received additional information from both the licensee and the consultant hired by the licensee following a reenactment of the incident. It was reported that, after setting up and taking two shots, the trainee noticed that the source got stuck in the guide tube. The trainee did not have his alarming dosimeter turned on, and he did not have his survey meter close by. The trainee believed the source was back in shielding, and he continued to work. He replaced the film, repositioned the tip of the guide tube, and cranked the source back out although it was already out. He repeated this a total of four times before he noticed that the source lock indicator was not in the shielded position. The trainee then checked his dosimeter and found it off scale. He immediately reported this to the trainer which began the source retrieval event wherein they expanded the boundary, maintained security, and waited for the associate radiation safety officer to arrive. The film for the first two shots came out as expected, but the film for the last four shots came out black indicating that the source was near the film long enough to overexpose those four. This would indicate the source did become disconnected after the second shot. Based upon measured times and distances during the re-enactment, a whole-body dose of 38 R to the trainee has been reported TO this Department. The estimate for dose to each hand was reported to be 18 R. The trainee had left his badge in the truck so it will not be helpful in verifying these values. Dose to the trainer was 5 mrem. The trainer was 50 feet away during this event. Based upon this information, this Department is adding the following reporting criteria to this event: 20.2202(a)(1)(i) - Overexposure event involving byproduct, source, or special nuclear material possessed by the licensee that may have caused or threatens to cause an individual to receive a total effective dose equivalent greater than or equal to 25 rems (0.25 Sv). This Department will be reviewing the dose calculations and will provide an assessment with the final NMED report. Notified Young (R4DO), Einberg (NMSS), and NMSS Events by email. |
| ENS 56752 | 20 September 2023 22:33:00 | The following information was received from the Texas Department of State Health Services (the Department) via email: On September 20, 2023, the Department received notification of a lost moisture density gauge. The gauge is a Troxler 3430 (serial 39365) with 40 millicuries of americium-241 and 8 millicuries of cesium-137. The gauge was last seen at a job site with the licensee reporting that the handle of the gauge was locked. The gauge was placed inside a transportation case which was also locked. At the job site, the package was placed inside a holding frame in the back of a pickup truck, but the chains were not secured to the case. The tailgate of the truck was also left down. The technician drove about a mile down the road. Someone honking at him alerted him to the fact that the tailgate was down. He pulled over and found the gauge was missing and started searching for it. He alerted his radiation safety officer to the loss and the licensee now has several crews searching for the gauge. The licensee has reported that they believe the gauge might have been picked up by someone and has contacted the state police. This Department has also contacted the State, county, and local city emergency management coordinators. The licensee reported that with the device inside the case they do not expect significant exposure to anyone, but they would expect some exposure in an unrestricted area should someone get near the case. This investigation is ongoing and further information will be provided per SA-300.
The following information was received from the Texas Department of State Health Services (the Department) via email: The Department was contacted by the licensee's radiation safety officer (RSO) who reported the licensee's Regional Director was on-site and had checked with the local pawn shops. The director provided a picture of the device and offered a reward for the return of the gauge. The director did not receive any additional information. RSO stated they had talked to an eyewitness who said they saw the gauge fall out of the truck and then a few minutes later a black pickup truck pulled up and put the gauge in the back of their truck. The RSO stated there is camera footage of the area near where the gauge was dropped (which is at the exit gate to where they were working) and they have viewed the footage for the time they believe the gauge would have been picked up. The gauge did not appear in the video, but the video did help establish an elapsed time of 15 minutes between when the technician left the site until they returned. A second individual stated that there was a contractor working at the same site that had a dark colored truck and had left shortly after the licensee's truck left the site. The licensee has requested additional video footage to see if they can identify that truck. Notified the R4DO (Groom). Emailed NMSS, ILTAB and Mexico (CNSNS). Texas Incident Number: 10052 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 56708 | 1 September 2023 18:39:00 | The following was provided by the Texas Department of State Health Services (the Department) via phone and email: On September 1, 2023, the Department was notified by a general licensee that a generally licensed NRD, LLC device containing 10 microcuries (original activity on June 8, 2022) of polonium-210 was lost. This is greater than 10 times the Appendix C value of 0.1 microcuries. The device was to be disposed of after the general licensee switched to another non-radioactive material method of eliminating static. However, the device was believed to have been thrown away in municipal waste before this could happen and was last seen on May 12, 2023. The device is not expected to provide significant dose to anyone. The licensee does not believe this device would pose a safety or health risk to the public. Further information will be provided per SA-300. Texas NMED: TX 230038 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 56624 | 16 July 2023 11:16:00 | The following report was received by the Texas Department of State Health Services (the Department) via email: On July 16, 2023, the Department was notified of an industrial radiography source that was discovered to be not connected on July 15, 2023. The licensee reported that the camera was a QSA Delta 880 with serial number D11651 which contained a 31.5 curie Ir-192 source with serial number 72211M. The radiography crew had completed their first exposure and tried to crank the source back in, but it would not lock. After several more tries, they reported the incident to their site radiation safety officer (RSO). The RSO instructed them to expand the barrier and maintain constant surveillance. When the RSO arrived, he checked the dosimetry of the two radiographers and found they were both around 1 mR. He tried cranking the source back in and found that it would not lock. He also found that the survey meter readings were not changing so he concluded the source was not connected. Using 6 foot tongs, he was able to manipulate the guide tube and get the source to drop out. He then covered the source with about 150 pounds of lead such that the exposure rate was down to 30 mR/hr. He then connected the source to the drive cable and cranked it back into the locked position. The RSO received about 14 mR to both hands and whole body. Another worker who assisted with the lead received about 10 mR to the whole body. Badges have been sent in for processing. Further information will be provided per SA-300. Texas Incident Number: 10040 Texas NMED Number: TX230031 |
| ENS 56525 | 18 May 2023 19:11:00 | The following information was provided by Texas Department of State Health Services (the Department) via email: On May 18, 2023, The University of Texas MD Anderson Cancer Center (the licensee) reported to this Department that they had discovered a technician and package with contamination of around 12,000 dpm (disintegrations per minute). The licensee's technician picked up the bag (package) with their bare hands. They then did a wipe test of the bag and found that it was contaminated. They also discovered that both their hands were contaminated. They washed repeatedly which reduced the contamination on their hands but did not eliminate it. The licensee believes that the remaining contamination has been absorbed into their skin and that it is no longer removable. The technician has gone home with instructions to continue wearing gloves. The technician is pregnant, and the licensee plans to perform a thyroid check tomorrow. The bag had elevated readings at the handle, but the contamination seemed to mostly be at the top right of the bag where the zipper handle was located. The licensee has not found contamination in any other areas of their facility. The licensee used a well counter to try to determine the isotope and believes it is either 5 microcuries of technetium-99m or 2 microcuries of iodine-123. A comparison of activities of the following day will determine which isotope it is since there is a significant difference in half-lives. The container with the ordered 10 millicuries of iodine-123, which was inside the bag, was wiped and found to not be contaminated. The nuclear pharmacy that supplied the bag and material inside the bag did wipe tests of the driver's hands, the steering wheel, pedals, the rack the bag would sit on, and the hand truck that the package would have been placed on. They did not find any radiation above background. They also performed wipes and surveys within their facility and again did not find any contamination. The worker who prepared the material at the pharmacy in the morning only drew iodine-123 for this single package. All other iodine-123 packages were pre-prepared. The pharmacy sent around 45 packages out in the morning to many medical facilities. None have reported contamination. The truck only carries packages from this single pharmacy. The Department has asked both facilities to continue to look for contamination and has recommended that the technician wear cotton gloves inside of the other gloves to hopefully get the hands to sweat the material out into the cotton. Texas incident number: 10020. |
| ENS 56506 | 6 May 2023 00:52:00 | The following information was provided by the Texas Department of State Health Services (the Department) via email: On May 5, 2023, the Department received a notification of a source retrieval incident. A team of radiographers was working at a fab shop late at night using a QSA Delta 880 camera with a 45 curie selenium-75 source. While the source was out, a small pipe fell onto the guide tube and crimped the line. The radiographers were unable to retract the source back into the camera and pushed it back out to the collimator. They then watched the barrier that was at slightly less than 2 mR/hr until the RSO (Radiation Safety Officer) arrived. The RSO, who is authorized on Texas license for source retrieval, then placed lead filled bags on the source that was still within the collimator. He then proceeded to uncrimp the line, and after the 5th attempt, he was able to retract the source back into the camera. The two radiographers did not receive additional dose, but the RSO who retrieved the source did receive 108 mrem. No one else was present because of the late hour. A survey of the camera was performed after the retrieval with no change compared to before the incident. Further information will be provided per SA-300. Texas Incident Number: 10015 NMED Number: TX230020 |
| ENS 56483 | 21 April 2023 15:55:00 | The following information was provided by the Texas Department of Health Services (the Department) via email: On April 21, 2023, the Department was notified of a gauge with a shutter that could not be moved into the closed position because the lever which moves the shutter broke off. The owner of the gauge reports the lever broke because of corrosion and vibrations. The gauge is a Texas Nuclear 5204 with 8 curies of cesium-137. It is on the side of a dredging vessel that is dredging the entrance channel in Corpus Christi in a 24 hours of work per day operation. During dredging operations, the gauge is normally in the open position and the beam is directed inwards towards the ship. The crew of the vessel normally avoid that side of the vessel and will continue to do so. A survey of the gauge was performed and there is no change. The owner of the gauge reports that they expect the gauge to be repaired by a servicing company on May 9, 2023. The Department discussed the possibility of the vessel being docked with the gauge still in the open position and will continue to monitor the situation. Further information will be provided per SA-300. The Department will also forward this to the Florida Radiation Control Program as this is a Florida licensee operating in Texas under reciprocity. Texas incident number: 10013 |
| ENS 56384 | 2 March 2023 17:28:00 | The following information was received from the Texas Department of State Health Services (the Department) via email: On March 2, 2023, a licensee notified the Department that they were unable to retract a 79.6 Ci iridium-192 source to a Delta 880 camera at a temporary job site on March 1, 2023. After an exposure, the cable was cranked in but would not lock. The technicians cranked the cable back to the collimator and called a radiation safety officer (RSO). The RSO arrived at the site and found that both technicians had extended the boundary to 1-1.5 mR/hr. He then checked the dosimetry for both technicians and found both had received about 20 mR. The RSO investigated the source and determined that it had become disconnected from the wire at the point where the wire connects to the pig tail. The source was determined to still be in the collimator. A lead blanket was then used to cover the collimator. The crank-out and guide tubes were then replaced. The end of the pig tail was slowly exposed so that the wire could be connected by hand. The source was then retracted successfully back into the camera. The RSO wore a direct reading dosimeter on his hand while doing this and reported that his hands received around 600 mR. His whole-body dosimeter measured around 400 mR. His badge has been sent in for analysis. The technicians and public did not receive additional dose from this incident. Texas Incident Number: I-9997 |
| ENS 56334 | 3 February 2023 11:28:00 | The following report was received via email from the Texas Department of State Health Services (the Agency): On February 3, 2023, the licensee notified the Agency of a stolen moisture density gauge. The gauge was left chained to the back of a truck at a (Borger, TX) hotel overnight. At around 0700 CST, the technician found the chains cut. The incident was reported to the local police department (and the State and local emergency management coordinators). The licensee reported that the gauge was in the safe position within a Type A Package which had both sides of the package locked. The licensee reported that the gauge is a CPN-MC1-DR model that contains 50 millicuries of americium-241 and 10 millicuries of cesium-137. The serial (number) for the gauge and the two sources was reported to be MD40301932. Further information will be provided per SA-300 when obtained. Texas Incident No: I-9985 Texas NMED No.: TX230003 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 56276 | 16 December 2022 18:28:00 | The following information was provided by the Texas Department of State Health Services (the Department) via email: On December 16, 2022, the Department received calls from a licensee reporting an equipment failure with a moisture density gauge. The licensee has been unable to retract the rod with cesium-137 back to the fully shielded position and the source is sticking out about 4 inches. This is for a Humboldt 5001 gauge with 40 millicuries (mCi) of americium (-241) and 10 mCi of cesium-137. The rod is presently in the ground to maintain shielding and will be transported back to the storage site with the rod in a bucket of sand. The licensee plans to transport the gauge the same way to a repair facility tomorrow morning. The dose to personnel has not been above normal working conditions but there may be some dose during transportation. The licensee was reminded to minimize dose as much as possible. Further information will be provided per SA-300. Texas Incident Number: 9974 |
| ENS 56237 | 23 November 2022 11:30:00 | The following information was provided by the Texas Department of State Health Services (the Department) via email: On November 23, 2022, the Department was notified by a licensee of a medical event involving Yttrium-90 Sir-Spheres. The procedure took place on November 21 and was thought to occur without incident, but when the tubing was measured on November 22, they found significant activity indicating that only 61.6 percent of the intended activity or material had been inserted into the patient. The intended activity to be inserted was 13.4 mCi and the actual activity delivered was 8.26 mCi. The room was surveyed after the procedure and no significant leakage or contamination was found. The patient and prescribing physician should be notified today. Further information will be supplied per SA-300. The investigation is ongoing. Texas Incident Number: 9965 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 56066 | 24 August 2022 16:36:00 | The following information was received from the Texas Department of State Health Services (the Agency) via email: On August 24, 2022 the Agency received a report of an equipment failure from a general license acknowledgement (GLA) licensee. A lead plate on the shutter was found to no longer be attached to the shutter. An initial possible cause is that vibrations allowed the lead to go through the screws and become detached. The shutter was removed from service and placed into storage. A lead blanket is covering the gauge and a survey found no elevated readings. The device is approximately 8.5 years old and contains a 200 milli-Curie Cs-137 source. Nobody was believed to have received a significant dose from this issue. The licensee is taking pictures and will try to better determine the cause. The device will be repaired by a service company on August 26, 2022. An investigation is ongoing and further information will be provided per SA-300. Texas Reference Number: 9951 |
| ENS 56031 | 4 August 2022 16:42:00 | The following information was provided by the Texas Department of State Health Services (the Agency) via email: On August 4, 2022, this Agency received information that a former licensee was trying to obtain 500 microCi of Am-241 without a license. The material would reportedly be used for calibration. The issue was reported to the appropriate Agency in California because that is where the seller is located. An informal report was made to the NRC in Arlington, Texas. It was decided that this needed to be reported to the FBI which was accomplished on this same day. The seller has reported that they will not provide a quote to the former licensee and hence will not be supplying the material. It is not clear if this is a misunderstanding or an attempt to gain material while bypassing regulations. This Agency will not investigate this matter immediately but will give the FBI some time to investigate. No further information is expected in the near future, but information will be provided when obtained per SA-300. Texas Incident Number: I-9944 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 55839 | 12 April 2022 16:37:00 | The following information was received from the Texas Department of State Health Services (the Agency) via E-mail: On April 12, 2022, the Agency received an email from a licensee regarding an Am-241 source that was no longer within the source holder of a Troxler Model 3430 (source assay date 9/29/1997 and serial 28367). The source capsule, source holder, and source cap were all loose within the gauge. This was the first notification to this Agency of this issue. The licensee reported that on March 25, 2022, a licensee technician reported measurement issues with this device. A survey of the device did not find any elevated readings. The device was pulled from service and inspected on March 30, 2022, at which point the loose components were discovered. This licensee had experience with this issue before (see EN 55774) and repaired the assembly using Loctite. Licensee reports the source is not leaking and is secured within the source holder. Investigation is ongoing and additional information will be provided per SA-300. Texas Incident Number: I-9925 |
| ENS 55571 | 11 November 2021 11:55:00 | The following was received from the Texas Department of State Health Services (the Agency): On November 10, 2021, the Agency received notification from (the Radiation Safety Officer) RSO of the licensee reporting that a yttrium-90 TheraSphere administration with an intended activity of 44.8 mCi (120 Gy) to be inserted resulted in only 18.7 mCi inserted into the patient with the remainder still in the delivery system. RSO reported the procedure was completed indicating there was no stoppage due to patient or otherwise intervention. This was 41.6 percent of the prescribed activity inserted into the patient and at present an unknown dose. The target was a tumor in the liver. A survey of the room was done with no contamination found. Texas Incident: I-9895 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 55519 | 13 October 2021 11:05:00 | The following was received Texas Department of State Health Services, via email: On October 13, 2021, a licensee reported a moisture density gauge was stolen overnight. The gauge was taken from the back of a truck between 18:00 (EDT) on October 12, 2021 and 06:00 (CDT) October 13, 2021. The gauge was stored and locked within the carrying case but was not secured to the truck. The gauge is a Troxler model 3411 serial 11111 containing 8 mCi of Cs-137 with serial 47- 6513 and 40 mCi of Am-241 with serial 40-8612. Because the gauge was secured within the case it is not expected to provide any significant dose to anyone. The incident was reported to the local police department. More information will be provided per SA 300 as it is obtained. Texas Incident Number: 9890 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 55438 | 30 August 2021 17:30:00 | The following was received from the Texas Department of State Health Services via email: On August 30, 2021, a health physics service contractor reported a stuck shutter for the licensee. During a 6-month inspection check, the shutter was discovered to be stuck in the open position, which is the normal operating position. The contractor reports there will be no additional dose risk to personnel outside of the normal operations. The shutter is a Vega model SH F1B with serial number ov0895 with a 70 mCi Cs-137 source. The serial number for the source and the installation date were not known at the time of the initial reporting but will be given in the report. The contractor indicated the manufacturer would be contacted for repairs or replacement. Additional information will be provided per SA-300. Texas Incident Number: 9880 |
| ENS 55361 | 19 July 2021 16:02:00 | The following information was received via E-mail: On July 19, 2021, the licensee notified the Agency (Texas Department of State Health Services) that one of its radiographer's personal dosimetry badge results for the monitoring period of June 2021 indicated a deep dose equivalent (DDE) of 5,114 millirem. The radiographer had terminated his employment with the licensee on July 6, 2021. The licensee has contacted the radiographer by phone and the radiographer stated he did not know how it could have happened. The licensee is investigating to determine if the dose was to the radiographer or to the badge only. The licensee also reported that the radiographer had more than one day of work and that the dose to this badge did not occur all within a 24 hour period. An investigation into this event is ongoing. Texas Incident No.: 9870 |
| ENS 56003 | 18 July 2022 18:46:00 | The following information was provided by the Texas Department of State Health Services (the Agency) via email: On July 18, 2022, the Agency received a report of two generally licensed devices that were lost. The two devices are NRD P-2042-1000 Staticmaster devices containing 5 mCi of Polonium-210 each. The notification to the Agency was a written letter from the licensee and the Agency was unable to reach the responsible person for these devices who is reportedly sick. Additional information will be provided when it is obtained per SA-300. Texas Incident Number: I-9942
The following information was received via E-mail: On July 18, 2022, the Agency received a notification of two generally licensed devices that were lost. The two devices are NRD P-2042-1000 Staticmaster devices containing 5 mCi of polonium-210 each. The notificaiton by general licensee was received as a written letter and the Agency was unable to reach the responsible person for these devices who is reportedly sick. The Agency was able to obtain additional information today, July 19, 2022. One source was lost around October of 2021. The other was lost in May 2021. Both sources were believed to be lost in different buildings on the same site. The licensee has searched for the sources and will continue to do so. They will also contact former employees and request their assistance. Further information will be provided to NMED per SA-300. Notified R4DO (Gaddy) and via E-mail ILTAB and the NMSS Events Notification E-mail group. 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 55289 | 4 June 2021 16:52:00 | The following was received from the State of Texas, Department of State Health Services (the Agency) via email: On April 21, 2021 a Licensee found that the count rate for one of their gauges was the same with shielding present and not present. The count rate was consistent with previous count rates with the shielding present. The Licensee shut down the device and called for service and repair who replaced two items resulting in the device working properly again. The Licensee then sent a letter dated May 2, 2021 to the Agency who received/stamped it on May 10, 2021. The letter was eventually passed to Randall Redd of the Investigations group on June 4, 2021. The letter provided a serial number for something. The Licensee was contacted on June 4, 2021 multiple times but I was unable to get any further information as multiple people are not in the office but on vacation. One person was able to give me the license number for the Licensee but when they looked at the serial number in the report it did not match any of the devices on their inventory. A meeting is set up for late Monday (June 7, 2021) to get this information. Additional information will be provided in accordance with SA-300. Texas Event Report Number: 55289 |
| ENS 55176 | 7 April 2021 16:46:00 | The following was received from the Texas Department of State Health Services via email: On April 7, 2021, the licensee reported that a significant amount of Y-90 Theraspheres leaked out of the connection between the tubing and the catheter during a therapeutic procedure in which 24 mCi (a prescribed dose of 200 Gy) was to be delivered to the liver. The liquid was observed dripping out of the connection between the patient catheter and tubing onto the towels and drapings. The dose to skin of patient and worker cleaning up is not known because of the apparently large amount of contaminated towels and such. The (Radiation Safety Officer) RSO will attempt to address this and the cause in the coming days as the activity decreases. The RSO reports that both the patient and patient's physician were notified within 24 hours. More information will be provided as it is obtained in accordance with SA-300. Texas Incident #: I-9837 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 54585 | 13 March 2020 19:28:00 | The following was received from the State of Texas via email: On March 13, 2020, (the Texas Department of State Health Services) was notified by the Houston Methodist Hospital of a medical event. The patient was to receive 18.4 Gy of therapeutic dose from a Novoste Beta-Cath system Sr-90 source (system serial no. 89670, source train serial no. za925). When the procedure began, the command was sent to the system to deliver the source. The source did not appear within the fluoro field as expected after 10 seconds and the command was sent to the system to retract the source. The source failed to retract. The oncologist manually removed the catheter from the patient and found the source stuck inside. It is now back in the system. The licensee has been reminded that they need to notify the referring physician within 24 hours. An investigation into this event is ongoing. More information will be provided when obtained in accordance with SA-300. Texas Incident Number: 9751 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 54579 | 10 March 2020 18:21:00 | The following information was received from the state of Texas via email: On 10 March, 2020, the Agency (Texas Department of State Health Services) was notified of a gauge with a stuck shutter in the open position. The gauge is a Berthold Model LB7440L with a 5 mCi Cs-137 source with serial 186-1-88. This gauge normally operates with the shutter in the open position. There is no increased risk of exposure to any individual. An investigation into this event is ongoing. Texas Incident #: 9750 |
| ENS 54540 | 24 February 2020 19:10:00 | The following is a synopsis of a event reported by the state of Texas via email and phone call: On February 24, 2020, the Texas Department of State Health Services (Agency) was contacted by the Braun Intertec Corporation RSO to report a stolen moisture density gauge. The gauge was last seen on February 19, 2020 at the end of work in McKinney Texas. It was locked in a box in the back of a truck which was then driven to Euless, Texas where it reported to stay until February 24, 2020. The truck was then driven to a jobsite in Richardson, TX on February 24, 2020 at which point the employee realized that the locks were gone and the moisture density gauge was removed from the box in the back of the truck. Euless Police were notified. The activity for the density gauge is estimated to be 10 mCi Cs-137 and 40 mCi of Am241/Be. An investigation into this event is ongoing. More information will be provided when obtained in accordance with SA- 300. Texas Incident number: 9746
The following information was received from the state of Texas via email: On June 17, 2020, the Agency was notified by a steel mill in Midlothian, Texas, that it had found a moisture/density gauge in a load of metal from a recycler. The serial number was checked and it was determined to be this licensee's gauge that was stolen February 24, 2020. The licensee was notified and picked up the device on June 18, 2020. The licensee transported the device to a manufacturer's facility in Arlington, Texas, and transferred it for disposal. The manufacturer will complete leak tests and provide the licensee with the results. (There were) no exposures that would exceed any regulatory limit at the steel mill. Investigation will continue to determine if any exposures occurred at the recycler and if the recycler can provide information on where, or from whom, it got the device. More information will be provided as it is obtained in accordance with SA-300. Notified R4DO (Warnick), NMSS Events Notification (email), ILTAB (email), and CNSNS (email). THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 54534 | 20 February 2020 17:50:00 | On February 20, 2020, the Radiation Safety Officer for the Licensee notified this Agency of a medical event involving yttrium-90 Theraspheres. The prescribed dose was 120 Gy but only 85.2 Gy was administered with the remaining intended dose left in the tubing. The remainder could not be flushed out and the procedure was halted. The Licensee will meet with the manufacturer next week at the Licensee's facility to address this issue. This investigation is ongoing. More information will be provided when obtained in accordance with SA-300. Texas Incident Number: I-9745 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. |