Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 46815 | 3 May 2011 20:12:00 | On May 3, 2011, the Agency (Texas Department of Health) was notified by the licensee that a Troxler Model 3430 moisture/density gauge had been stolen from the back of one of their trucks. The gauge was stolen at the intersection of Nalor and North Main in Houston, Texas. The gauge contains a 40 milliCurie Americium (Am) - 241 source, and an eight milliCurie Cesium (Cs) -137 source. The licensee reported that their technician had completed his work and returned to the licensee's facility. When the technician went to the back of the truck to get the gauge, he found the gauge missing, one chain and lock missing, and the other lock had a busted bail. The technician contacted the other licensee's technicians who were at the work site to see if any of them had the gauge. No one did. The technician contacted his manager and reported the missing gauge. The licensee contacted local law enforcement and notified them of the theft. The Agency has sent notification of the theft to the Texas Association of Pawn Brokers. Additional information will be provided as it is received in accordance with Reporting Material Events SA-300. The serial number of the gauge is 63670. The source numbers are 78-6298 and 77-9880. Texas Incident: I-8841
On May 7, 2011, local law enforcement reported to a residence due to a domestic dispute call. The police saw a radiation symbol on the gauge case, confirmed it was stolen, and confiscated the case and gauge. The Troxler model 3430 moisture/density gauge serial # 63670 was returned to the licensee. The gauge was inspected and returned to service. Notified Mexico via fax. Notified R4DO (Walker), FSME DEO (McIntosh). 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 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 46810 | 3 May 2011 11:25:00 | On May 2, 2011, the Agency (Texas Department of Health) was notified by the licensee that during routine checks on an Ohmart/Vega nuclear gauge model SHD containing 250 millicuries of Cesium (Cs) 137 (original activity), the shutter was found stuck in the open position. The gauge is mounted on a tank and is located 100 feet above ground and does not create an exposure risk. The gauge is used for level detection. The licensee has lubricated the operating mechanism several times to get the shutter to operate, but it remains stuck. A service provider will be contacted to conduct repairs if needed. The gauge was installed in 1990 time frame and is to be replaced in the future. Addition information will be provided as it is received in accordance with SA-300. Texas Incident Number I-8840
On May 3, 2011, the Agency was notified by the licensee that the gauge was working as designed. The repeated lubrication of the operating mechanism was the only method used to make the repair to the gauge. Additional information will be provided as it is received in accordance with SA - 300. Notified R4DO (Proulx) and FSME EO (McIntosh). |
| ENS 46787 | 26 April 2011 09:58:00 | The following information was provided via email: On April 20, 2011 the Agency was notified that a radiography source had failed to retract to the shielded position because the material being radiographed had fallen on the guide tube and crimped it. Following company procedures, the Radiation Safety Officer was notified and the area was restricted to avoid public or excessive employee exposures. Several entries were made to shield the source and allow an authorized individual to straighten the crimped portion of the tube within tolerable radiation fields. After several other trips to place lead shot on the source, four additional trips were required before the crimp in the source tube was straightened and the source was retracted into the shielded position. The source retriever and his assistance received nominal radiation exposures during the procedure and no public exposures reportedly occurred. No violations were cited. Texas Incident #: I-8838. |
| ENS 46534 | 11 January 2011 18:27:00 | A pool type irradiator experienced a drive mechanism failure on one of the two racks. This caused the 1.2 M Curie of Co-60 to remain stuck in the retracted position. It remained there for one hour until the operators discovered that a spool valve was stuck. Once the valve was freed the source rack returned to the pool as normal. The licensee is investigating the equipment malfunction and will submit further information when available. There were no personnel injuries. TX Incident No: I- 8809
At approximately 1900 (CST) on January 10, 2011, a licensee operating a pool-type irradiator in El Paso, TX, experienced a drive mechanism failure on one of two source racks. This caused the 1.2MCi of Cobalt-60 (Co-60) to fail to descend into the pool. The source rack remained in the lifted position for approximately one hour until the operators discovered that a spool valve was stuck. A piece of pipe was removed to allow the piston to vent, thus bypassing the valve. The source rack returned to the pool in a controlled, normal descent. The licensee is investigating the equipment malfunction and will submit further information when available. The initial report stated that the source rack had remained in the retracted position. Wording has been changed to more clearly describe, and clarify, that the source rack was stuck outside the pool (unshielded) for approximately one hour. There were no problems with the rack or the sources, the only issue was the spool valve malfunction. Notified R4DO (Hagar) and FSME (Villamar) |
| ENS 46361 | 25 October 2010 13:30:00 | The following information was received from the State of Texas via email: On October 25, 2010, the licensee reported that while making preparations to perform plant maintenance, the shutter on a Ohmart Corporation model SH-F2-45 nuclear gauge containing 60 milliCuries (original activity) of Cesium (Cs)-137 was found to be stuck in a partially opened position. The licensee stated that they are going to shield the source to reduce the dose rate to below 2 millirem/hour, remove it form the vessel, and lock it in their Radioactive Material storage building. No significant exposure has occurred due to this event. The licensee has contacted the manufacture for repairs or replacement of the gauge. The cause for the event is under investigation. Additional information will be provided as it is received IAW SA 300. Texas Incident #: I-8795 |
| ENS 45988 | 8 June 2010 17:15:00 | On June 8, 2010, the State of Texas was notified by the licensee that during routine chart review, they determined that over a six month period, five patients received 30% to 50% less than prescribed dose. All the patients underwent High Dose Rate Brachytherapy using a Ir-192 Gammamed device. The licensee is still investigating an evaluating patient outcomes due to the under dosages. It is unknown whether the patients and their prescribing physicians were notified. Texas Incident No.: I-8751 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 45819 | 7 April 2010 19:10:00 | A scrap yard located in Seguin, TX was processing a rail car loaded with scrap metal when their radiation detectors alarmed. When the load was investigated a Varian Linear Accelerator was found (serial number 71). The source of radiation was determined to be from approximately 100 lbs. depleted Uranium contained in the unit. The shipment originated from Austin, TX. * * * RETRACTION FROM RAY JISHA TO CHARLES TEAL ON 4/8/10 AT 1302 * * * Additional investigation determined that the Varian CLINAC 18 accelerator does not contain depleted Uranium. The shields in this model are made of tungsten. |
| ENS 45479 | 6 November 2009 14:31:00 | On November 6, 2009, the State of Texas reported that a Troxler moisture density gauge was lost and recovered by the Troxler Electronic Laboratories, Inc. The event occurred approximately one to two years ago. The density gauge was recovered two days after it was lost. The State of Texas will provide updates as more information is available. The gauge contained an 8 mCi Cs-137 and a 40 mCi Am/Be-241 source. Texas Incident # I-8686
On November 4, 2009, while conducting a routine inspection, an agency inspector found an event that involved a Troxler moisture/density gauge model # 4640 containing one 8 millicurie Cesium (Cs) - 137 source, which was lost during shipment and returned to the licensee the next day, intact and with no damage. The gauge did not contain an Americium source. The case did not have any scuff marks on it. Neither the licensee or the shipper had notified the agency of the event. They believed that it was not reportable since there was no chance that someone could have received an exposure from it and it was lost for only one day. The licensee also believed that the shipper would be required to make any required notifications. The licensee was informed that they would have been required to notify the agency of an event (and it) would have been reportable. The licensee stated that they believed the gauge had fallen off of their truck. The truck used had a faulty latch mechanism on the door. The driver received additional instruction on securing the door. Notified FSME (Lewis) and R4DO (Hagar). |
| ENS 45435 | 15 October 2009 15:55:00 | The following information was received from the State of Texas via email: On June 29, 2009 Hotwell US LTD received a new shipment of two tritium well logging tools from their manufacturer in Austria. The tools each contain a 1.8 Curies (Ci) tritium sealed source inside a 15,000 psi pressure housing. These tools were slated for sale and delivery to Competition Wireline (NRC License No. 25-27802-1) out of Billings, Montana. After arriving at the facility in Houston, Texas, the tools were checked and shipped via (common carrier) to Competition Wireline. One tool (No. 33264) arrived at Competition Wireline on July 1, 2009. On July 6, 2009, Competition Wireline verified to Hotwell US LTD that the other tool (No. 33284) had been received. On October 13, 2009 Competition Wireline reported to Hotwell US LTD that after a general inventory of equipment, they could not locate one of the tools (No. 33284). The licensee has alleged that (the common carrier) never delivered the tool and found that it was last tracked to Memphis, Tennessee. (The common carrier) now shows the package as 'In Transit'. Competition Wireline has notified (the common carrier), and (the common carrier) is conducting an investigation into the location of the package. The missing tool is described as follows: Tool No. 33284
Monoblock No.: 99448
Model No.: ING-10-50-120-TBT
Description: 84 x12 x8 Black Crate
Texas Incident Number I-8677. 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 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 45439 | 15 October 2009 18:04:00 | Received a call from State of Texas concerning an incident that occurred 10/14/09 at a temporary jobsite in Texas (location unknown). The company (not identified in the call) is located in Pasadena, TX. The State of Texas representative said that the Radiographer failed to follow procedures and connect the guide tube before cranking out the source. The source subsequently struck the wall and disconnected. The company RSO who is qualified for source retrieval recovered and secured the source. His extremity dosimetry indicated 57 mrem with a whole body dose of about 90 mrem. Details of the incident including licensee name and license number will be provided by update.
The following information was received by e-mail: On October 15, 2009, the Agency (State) was notified by the licensee that on October 14, 2009, they experienced a source disconnect while using an Amersham model 660 radiography camera containing a 45.3 curie Iridium (Ir) 192 source. The Radiation Safety Officer (RSO) stated that two radiographers were setting up for their first shot of the day. The guide tube they had was too short, so one of the radiographers connected an additional guide tube to the end of the existing guide tube, while the other radiographer prepared to perform the shot. Neither of the radiographers attached the guide tube to the camera. They then cranked the source out of the camera to perform their first shot. This caused the source to be pushed out of the camera, onto the floor of the shooting bay, and against the wall of a shooting bay. The camera operator felt that he had cranked the source out farther than it should have traveled for the shot and stopped cranking the source. He then tried to return the source to the camera. When the radiographer retracted the drive cable, the source was left loose on the shooting bay floor. The radiographer approached the shooting area with his dose rate meter and found the dose rates were elevated. The radiographer then secured the area and notified the RSO, who is specifically authorized on the license for source retrieval. The RSO developed a strategy to reconnect the source, and then successfully cranked the source back into the camera. No one involved with this event received an exposure exceeding any regulatory limit. The RSO stated that their investigation into the event determined that the root cause for the event was the failure of the two radiographers to follow procedure. He also noted a failure of the two radiographers to communicate adequately. The RSO stated that they will retrain all of their radiographers regarding their procedures for the proper connecting and disconnecting of equipment to their exposure devices. He also stated that this training would be repeated in their annual training in 2010. Texas Incident: I-8678 Notified R4DO(Cain) and FSME (McIntosh). |
| ENS 45322 | 2 September 2009 10:43:00 | The following report was received via email from the State of Texas: A mobile slurry unit (authorized under TX license G02259) in which a 200mCi, Cs-137, Thermo Fischer Scientific Model 5190 density gauge was mounted, caught fire. This occurred at an oil field temporary job site south of Fort Worth, TX. It was relayed that the fire had melted the lead at the top of the shield exposing the source as evidenced by elevated readings with a survey meter. It is believed that the source remains in the holder and has not been breached. Further, the gauge housing is still intact and (the) plan (already instituted) is to have the manufacturer remove the gauge for disposal at their facility. The device and source serial number are B7274 and CN-3171 respectively. There was no exposure to anybody in excess of agency limits due to the manner in which the units were parked. Texas report # I-8662 |
| ENS 45267 | 17 August 2009 15:55:00 | The following information was obtained from the State of Texas via email: On the morning of August 17, 2009, a 79.1 Curie Ir-192 source in a Sentinel Model 880 exposure device (S/N D5517) could not be retracted into the fully shielded position. After several attempts to back the source out, it was surmised that the source remained at the end of the source tube and the Radiation Safety Officer (RSO) was notified. A 2 mR/hr line was established by the radiographers and the licensee's report indicated that visual surveillance was maintained at all times. The RSO then utilized additional shielding and remote handling tools to retrieve the source and place it into another camera. It was determined after the recovery that the ball shank broke from the drive cable leaving the source pigtail in the source tube. The RSO reported that all personnel were monitored with direct reading devices and no exposures exceeded regulatory limits. Source: QSA Global model 424-9, Serial #56552B Texas Incident Report I-8658 |
| ENS 45268 | 17 August 2009 17:40:00 | The following information was obtained from the State of Texas via email: In the afternoon of August 17, 2009, the licensee had concluded that four static eliminators, NRD Model P-2021-Y000 containing 500 microCi each could not be located and were presumed lost, probably discarded in the general refuse. The sources were removed from the machines they were mounted on while the area was undergoing some renovation or relocation of equipment. However, when the equipment in which the devices were housed were attempted to be placed back in service, the devices were noted as missing. Repeated attempts to locate the sources and devices have proved futile. Texas Report I-8659 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 44900 | 12 March 2009 15:04:00 | |
| ENS 44806 | 26 January 2009 17:29:00 | The following information was obtained from the State of Texas via email: (On January 25, 2009), a Thermo NITON Analyzer X-Ray Fluorescence Device Model XL3p 800 was stolen from Allied Alloys (located in) Houston, TX. The device contains a 30 mCi Am-241 source with either a QSA Global AMCL or IPL XFB-4 model source. The external radiation levels on the shipping case and instrument of <0.01 mRem/hr and the useful beam measurements are 0.3, 3, and 45 mrem/hr at 100, 30, and 5 centimeters respectively according to the SSDR sheet, MA-1159-D-102-B dated August 30, 2007. The company is considering a reward as the device is valued at $30K and a police report has been filed with (Houston Police Department). There is some suspicion of the device being stolen by a former employee as there were other articles of value in the direct vicinity of the analyzer and this was the newest model out of six in the possession of the company. The pertinent identification numbers of the Niton hand held analyzer are as follows: Model No. XL3p 800 Serial No. 31000 Americium 241 source SN: 07-232 Detector SN: 55276 Texas Incident No.: I-8602 * * * UPDATE FROM JISHA TO SNYDER ON 1/27/09 AT 0732 * * * The State of Texas provided the following information via e-mail: (The licensee is) not considering an award at this time. More cameras are being installed and all Nitons will be locked up in the main building (of the licensee's facility) where anyone going near the Niton storage area will pass through at least 4 cameras or more. The was the first noticeable break-in (that the licensee has) had in 5 years at this location. Notified R4DO (Cain) and FSME EO (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. |
| ENS 44725 | 17 December 2008 10:51:00 | On Wednesday, December 17, 2008 a Troxler moisture density gauge, Model 3430 (S/N 37875 with 8mCi of Cs-137 S/N 77-5152; and 40mCi of AmBe-241 S/N 78-2656) was stolen from the bed of a company pick-up truck along with some other field equipment. The transport case was chained as required by company procedures, but the entire case with gauge was noted missing when the technician briefly left the truck unattended. The chain had been cut and the theft was immediately reported to the Dallas Police Department. The area will be canvassed and dumpsters checked to see if the device had been inadvertently discarded. A reward will be posted through a notice that will be distributed to local authorities. TX Case Number I-8591. 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 44681 | 24 November 2008 13:20:00 | While at the office, Site002, on Sunday, November 23, 2008, the licensee had a truck with a gauge secured in the bed which was stolen by cutting the chain and lock. The employees had left to go to a jobsite and upon returning to the office noticed that the gauge had been stolen. The Dallas Police Department was notified and a report was filed. The Agency was notified at the start of business on Monday, November 24, 2008. The gauge was a Troxler 3430 (S/N 334330) and had two sources, 8mCi of Cs-137 (S/N 750-8953) and 40mCi of Am-241 (S/N 471455). TX Incident #- I-8582 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 44499 | 17 September 2008 13:52:00 | On September 17, 2008 the licensee reported that a(n) Ohmart/Vega (OV) model SH-F1 has a sheared bolt on the shutter handle which prevents it from closing. This device (S/N 1297GK) contains 20mCi of Cs-137 in a model OV A-2100 sealed source capsule. The manufacturer has been notified and will see to the proper repair or replacement of the gauge. No public exposures are likely to approach regulatory limits and the vessel has been posted to prevent entry. |
| ENS 44472 | 8 September 2008 12:34:00 | The licensee discovered that a Troxler moisture/density gauge was stolen sometime between 1600 CDT on 09/07/08 and 0730 CDT on 09/08/08. This was a Troxler Model 3430, S/N 29518 with two sources of 10mCi, Cs-137 and 40mCi, AmBe-241 stolen from a FUGRO consultants Inc. employee from a private residence in Waco, TX. This was reported to the Cities of Waco and Woodway Police Departments and filed under case # 08-21954 for the former. Please refer to TX incident # I-8551. 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 44426 | 19 August 2008 16:13:00 | Hospital cited for current calibration of SR-90 eye applicator. During previous inspection, after calibration, recalculation of recent treatments indicated 3 patients received 50% overdose over the past year. RSO reports Oncologist and referring physician were pleased with patients response to treatment. Texas Incident # I 8539 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 44422 | 19 August 2008 13:31:00 | On Friday, August 15, 2008, the agency (State of Texas) received a phone call left as a message for an employee out on leave that a moisture density gauge (Humbolt model 5001EZ) was stolen after it was left at a work site. It was apparently left out of the transport case and the technician was distracted with other duties. When the employee returned there was no trace of the device. The RSO stated that a full investigation will be performed to ascertain how the instrument was left unattended and the local law enforcement authorities have been notified. A $300 reward has been offered for return of the device. Incident Investigation Program (IIP) has notified LEA and pawn brokers to be on alert for stolen device. Company (and State Agency) will conduct a thorough investigation. Protocols for proper storage and handling of gauges will be stressed at a future safety meeting and all employees will receive training on the consequences of mishandling company property. Sealed sources :Radionuclide(s): 10 mCi, Cs-137 & 40 mCi, Am/Be-241 Serial Numbers: device 515; Cs-137, 8567GF; Am-241, NJ00479 TX-I-8541 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 44406 | 12 August 2008 09:08:00 | "On August 11, 2008, the agency received written notification from the Radiation Safety Officer (RSO) that a worker's quarterly film badge showed a reading of 40,080 mrem. Additional processing by the provider left the assessment as indeterminate however actual personnel exposure is beyond reality since the licensee is an operator (of) moisture density gauges only. A preliminary investigation has shown that the operator did not maliciously expose or tamper with the dosimeter and there was nothing unusual about the conditions of storage. The RSO stated that a full investigation will be performed to ascertain how the dosimeter received such extensive radiation exposure. The State of Texas will be conducting an on-site investigation. Texas Report Number: I-8533 |
| ENS 44335 | 3 July 2008 14:11:00 | A medical event occurred at 12:04 pm on July 2, 2008. The licensee is Baylor University Medical Center, License Number L01290. The unsealed source is Y-90 Therasphere microspheres for treatment of liver cancer. The prescribed dose is 100 Gray, and the prescribed dose range is from 95 Gray to 105 Gray. The activity of the Y-90 Therasphere microspheres was verified at 9:13 am - with 13.4 mCi in the vial - using the dose calibrator as per the manufacturer instructions. However when the dose was delivered the 3 way stop-cock was set erroneously and almost the entire dose was collected in the vent vial. Attempts to recover and deliver the misdirected dose was very limited. Post-administration, the residual activity in the original dose vial, the vent vial, and contaminated effects (catheter line, tubing, needles, towels, gauze pads, etc) totaled 12.046 mCi normalized to the 9:13 am verification time. Therefore, the estimated administered activity was approximately 1.3 mCi, administered on 2-July-2008 at 12:04 pm. This translates to approximately 8.7 Gray delivered to the treatment site (Liver Tumor). Essentially only 8.7% of the prescribed dose was delivered. The licensee is continuing the investigation. Texas event report I-8522 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 44133 | 11 April 2008 13:00:00 | The State of Texas reported that a 55 milliCuries strontium-90 beta applicator, Amersham Model SIA.20, is currently missing. The device was formally used at a cancer treatment facility in Plano, Texas, which has since filed for bankruptcy protection. The device was not returned to the authorized user upon sale of the property. The state believes the device is locked and stored in the building and is attempting to gain access through the bankruptcy trustee. The state is investigating and will provide further details at a later date.
The State of Texas has inspected the business and accounted for the missing beta applicator. Additionally, they have discovered some other nuclear source material. The state has served an impoundment order on the business and has secured all of the sources in the building pending additional investigation and follow-up. Texas Incident No. I-8500 Notified R4DO(Deese) and FSME(Kock). 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 43669 | 27 September 2007 15:15:00 | At 1030 hours the licensee reported that a Sentinel model 676AE (S/N AE1017) radiography camera with a 69 Ci Co-60 source (Make 424-13; S/N 2612) failed to retract to the safe position. After several attempts to retract the source and after a close inspection of the crank device, the Agency was notified and advice sought for authorized personnel who could safely retrieve the source. At 1400 hrs., the RSO had made arrangements with the manufacturer to provide a team equipped to deal with the emergency. The licensee is authorized for fixed site radiography for the facility that he owns. Due to Increased controls, surveillance will be maintained by additional security personnel until the retrieval team is on-site, either late tonight or early tomorrow, Friday 09/28/07. Texas event report: I-8445
Update, @ 0800hrs., Friday, September 28, 2007. The RSO for Matrix Metals called to report that the manufacturer's specialist arrived on the scene at ~2230hrs last night, Thursday, September 28, 2007 and the source was retracted to the save position within 20 minutes. As the source was in a shooting bay at this fabrication facility, no significant public or personnel exposures occurred. The RSO for the licensee and another authorized user remained at the facility to ensure constant surveillance as per IC requirements. Upon a more thorough inspection of the camera by the manufacturer's representative, a few mechanical issues were determined to be in need of further investigation so the device and source are being over packed today and returned to the manufacturer. A full report from the licensee will be filed" (with the state of Texas). Notified the R4DO (Johnson) and FSME (Wastler). |
| ENS 43644 | 15 September 2007 19:26:00 | At approximately 2200 hrs. on 9/14/07 during radiography work at a jobsite in Vidor, TX (30 miles north of Beaumont), two radiographers noticed that their pocket dosimeters read off-scale high (range 0- 200 m R). They were using a 94 curie Co-60 camera (QSA model 943, A424-14, S/N36391B) to take radiographic shots of a 6 inch thickness steel ladle and had just changed the film in the holder which was located about 7 inches from the exposed source behind the steel ladle. It appeared that the source had not retracted into its shielded volume. A specialist in source retrieval was brought to the jobsite and the source successfully returned to its stowed position. During retrieval the specialist's pocket dosimeter also went off-scale high (range 0-5 R) at which time he switched to a higher reading dosimeter (range 0-20 R) completing the task with an indicated dose of 13 R. The State of Texas was notified of the incident at 1804 hrs. on 9/15/07 and confirmed that the licensee was sending the individuals dosimetry off for emergency reading. Further, the State contacted REAC/TS (Radiation Emergency Assistance Center/Training Site) who recommended that these individuals be immediately medically examined with followup blood chemistry tests, i.e., CBC (complete blood cell), performed the following day to document any cytogenic changes. The State will conduct an investigation to determine the cause of the overexposures.
The State provided the following information via email: The two workers 200 mR dosimeters were off scale and it appears that they were working with the source not fully retracted as a crimp in the source tube was noted approximately 1.5 feet from the camera. A ladder was used to enter the ladle from one side and the source was positioned on the opposite side with a magnetic hold on device. It has been conveyed that the hold on device fell off at some time and damaged the source tube restricting the full retraction of the source for two shots with a survey being taken on the second shot and thus the source being discovered in the exposed position. The source retrieval was difficult apparently requiring the source to be fully extended so that the source tube could be manually stripped from the drive cable. This took reportedly 12 one minute maneuvers, lead shot bags used when possible." Blood was drawn Saturday and twice Sunday for CBC the results of which are to be faxed to REACTS. On Monday blood will be drawn with heparin/lithium for transport to REACTS for cytogenic analysis. Our inspector in the area is to conduct a recreation on the event today and more details will follow in a formal report. Texas report number I-8444 Notified R4DO (V. Campbell) and FSME EO (Morell), and IRD Manager (Blount) |
| ENS 43371 | 18 May 2007 15:08:00 | The RSO called to notify the Agency that for the April '07 dosimeter report, a reading of 5,131 mrem was assigned to the dosimeter worn by a radiography trainee. This individual is no longer employed by the licensee. According to existing radiation reports, the trainee was not actively involved in performing industrial radiography for the said time period. He also claims to have stored his badge in a trailer for at least five days of the month opening a question to deliberate tampering. Radiography with Ir-192 was being performed in the general area but the trainee alleges that his participation was limited to a barricade watch. Other personnel with Conam support this recollection. (The Texas Department of Health Incident Investigation Program) will submit a completed report when the licensee and the Agency complete the investigation. Event Report ID: 07-43371 Texas Incident No: I-8414 |
| ENS 43342 | 4 May 2007 11:40:00 | The following information was provided via e-mail: On Friday, May 4, 2007, around 10:20 a.m., the Agency received notification by Alliance Laboratories, Inc., that a 2002 metallic gray Dodge Ram 1500 pickup truck that was carrying a moisture/density gauge, Humboldt Scientific Inc, Model 5001, SN#4455, with two sources 11 mCi of Cs-137, SN 1654CM, and a 44 mCi Am-241, SN NJ04752, was stolen sometime between 0600-0800 hrs. from an apartment complex in Houston, Texas. Houston Police Department has been notified and the case number is 06-4781007B. The Agency also notified the (Headquarters) Operations Officer at the NRC, at 1040 hours, and the event number is 43342. Texas Incident Number: I-8409. 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 43163 | 13 February 2007 12:50:00 | The following information was received via email: On Tuesday, February 13, 2007, the Agency (Texas Department of Health) was notified of a series of at least five medical events that were discovered when an improper dose rate constant was used in the treatment planning of the therapeutic application of permanent implants. The radioisotope is I-125 and it was used exclusively for the treatment of prostate cancer. The range of misadministrations is 21-36% over that which was prescribed in the written directive. The licensee is investigating the situation that involved some 28 patients treated over the past year but only one patient complication has been reported thus far. The Agency is continuing to investigate the events with the licensee and will provide updated information as it is received. Texas Incident No.: I-8391 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 42997 | 16 November 2006 08:54:00 | At 2130 CST on 11/15/06, Schlumberger reported that a well logging tool was missing from the truck transporting the tool. The tool contained 1.5 curies of Tritium in a neutron target. It appears that the tool was lost or fell from the truck along a 50 mile portion of County Road 3169 in Zapata County, TX. A search for the tool is in progress.
At 2130 on Nov 15, 2006, a third party transport driver noted that he was missing a well logging tool that contains a neutron generator. The tool appears to have fallen off the truck along a fifty mile stretch of county road 3169 in Zapata county. The neutron generator contains 1.5 curies of tritium that is impregnated into the target of tube and is sealed within the tube and tool. No radiation is emitted by the generator and no public exposure is expected. Schlumberger personnel are searching the fifty miles of road and if the tool is not located on the first search, the Zapata county sheriff's office will be contacted. The search will continue at daylight. Additional notifications have been made to the Nuclear Regulatory Commission (NRC), U.S. Department of Transportation (DOT), and State Operations Center (SOC). The tool is a model 7158 manufactured by Schlumberger and is ~10 feet in length with an outside diameter of one and 11/16 inches. The device is made of stainless steel and has few markings on the exterior surface. The external surface of each neutron generator target is engraved with a target assembly I.D. number consisting of year-month-day (date of construction) and target position and the sequential serial number assigned to the neutron generator. After tritiation, the neutron generators have the model number (758, 761, or 762) and 'Radioactive H3' etched or engraved on the annulus of the end Kovar piece at the pinchoff end. The remaining annular space is taken by a second engraving of the serial number. Specific Item Missing: 1 11/16 inches OD logging tool continuing neutron generator approximately 108 inches (9 feet) long. The tool is made of steel and is cylindrical. Neutron Generator: Schlumberger Model 7158 covered by SSDR NR-316-D-101-S-1 (attached), Serial Number, 5710 Activity and Nuclide: 1.5 curies of tritium Description: Tritium is impregnated in a metal target contained within a sealed tube. The tube is sealed within an electronic housing (PNG-1032) and this electronic housing is contained with a well logging tool that is sealed and pressure rated to 15,000 psi. The generator only produces neutron radiation when high voltage is applied. R4DO (Johnson) and NMSS EO (Camper) notified. ILTAB notified via e-mail.
On 11/16/06, the licensee found the tool with the source intact, and it is reportedly at their Laredo facility. Notified R4DO (C. Johnson) and NMSS (G. Morell) and emailed to ILTAB. 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 42965 | 5 November 2006 18:07:00 | Two Radiation Oncologist Residents removed an LDR applicator from a cervical cancer patient. The applicator was supposed to have contained four Cesium-137 sources, 15 millicuries each, but only 3 of the sources were found. The patient's bed sheets had been changed and taken out of the room. Search for missing source is in progress. * * * UPDATE FROM R. JISHA TO P. SNYDER AT 0843 ON 11/6/06 * * * The lost source material was found in the laundry. The state continues to investigate. Further information will be provided later. Notified R4DO (J. Clark) and NMSS EO (M. Burgess). 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. 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 42839 | 13 September 2006 12:00:00 | The following information was received via email from Texas Department of State Health: At approximately 0920hrs on 09/13/06, while parked at a Texaco Station located at the corner of Miller Street and 1935 Jupiter, Garland, TX 75042, a radiography truck belonging to Bonded Inspection, Inc. was stolen. The driver was in the store talking with his supervisor while the keys were reportedly left on the floorboard. This vehicle had a large dark room style camper which contained a 95-100 Ci, Ir-192 source (s/n J254) inside a model Ir 100, INC camera (s/n 4189). The first contact to TX DSHS came (redacted) at 0950 hrs. (Redacted) the situation was also reported to local law enforcement authorities (LLEA), Garland PD. GPD response time was within 10 minutes and all Dallas Fort Worth (DFW) area LLEAs have been notified also. The JTTF coordinator for the DFW area FBI was notified as was the NRC, local DSHS inspectors and the TX State Operations Center. No malicious of suspicious intent is suspected at this time. The truck is described as a white Ford F350 pick-up conspicuously posted with Bonded Inspections, Inc. and it has flames as decals on the front. The TX license number is 5YL T51. TX Incident No.: I-8362 Notified DHS (Alex Constantopoulos), DOE (Mike Wyatt), EPA (Peter Menk), USDA (Chuck Brown), HHS (Mark McKinnon) and FEMA (Chris Liggett).
According to the Texas LLEA and the Texas Department of Health, the stolen truck and radiography camera were discovered at a business park in Dallas, TX approximately 3 miles from where they were taken. The source was found intact in the vehicle, and is in the possession of LLEA while they continue to investigate to find the person(s) responsible for the theft of the vehicle." Notified R4DO (Johnson), NMSS (Flanders), NRR (Case), DHS (Cassandra), DOE (Carolyn Lawson & Ronnie), EPA (Crews), USDA (Dean Giles), HHS (Smith), FEMA (Irwin Casto) and Mexico (via E-mail). 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 42500 | 14 April 2006 10:10:00 | The State provided the following information via email: Event type: Lost, two self-luminous, 20 Ci/ea., H-3, exit signs were discovered missing, presumed discarded. Event description: The manufacturer is SRB Technologies (Canada), Inc. 1) Model: BetaLux-E/Luminexit, SN 272697, Activity: 20 Ci; 2) Model: BetaLux-E/Luminexit, SN 270605, Activity: 20 Ci. One sign was noted as being discarded by the housekeeping staff and a subsequent inventory investigation showed that another sign was missing from an area that was renovated in August of last year." Texas Incident No.: I- 8325 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 42402 | 9 March 2006 14:05:00 | The agreement state submitted the following report via e-mail: Texas Incident No.: I-8311 Event date and time: February wear period Report Received Date: March 9, 2006 Event location: Brown and Root construction site, 14035 Industrial Road, Houston, TX Event type: Presumptive badge overexposure A radiographer trainee was working with a trainer at a construction site in Houston, TX when he noticed that his badge had fallen off approximately 6 feet from a 95 Ci, model G-60 Ir-192 source (S/N NA0502), SPEC model 150 camera (S/N 750). It is uncertain whether the trainee (name deleted) failed to report the incident to the radiographer, supervisor, or RSO. The incident was thought to have occurred in late February. The trainee is assigned other duties not involving exposure to radiation and the company is considering having cytogenetic testing performed. A second reading of the dosimeter by the company processing the device rendered an inconclusive result. The radiography company and DSHS staff are performing an investigation although the company is presuming the situation is a badge only exposure since the pocket dosimeters and processed dosimeter worn by the trainer were consistent with their typical monthly exposures of approximately 100 mRem. The film badge read 25.343 Rem. The state will be following up on this incident. |