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EN Revision Imported Date : 7/2/2020 AGREEMENT STATE REPORT - NUCLEAR GAUGE BROKEN LOCKING MECHANISM The following was received by the state of Texas via email: On May 12, 2020, the Agency (Texas Department of State Health Services) was notified by the licensee that the locking mechanism on a Endress Houser nuclear gauge model number FQG61 had broken off the gauge housing preventing them from locking the shutter in the closed position. The gauge contains a 100 milliCurie (original activity) cesium-137 source. The shutter operates normally. The licensee reported the gauge will not present an exposure risk to any individual. The licensee stated it is in the process of trying to schedule repairs to the gauge. Additional information will be provided as it is received in accordance with SA 300. Texas Incident Number: 9766

• * * UPDATE ON 7/1/2020 AT 1312 EDT FROM KAREN BLANCHARD TO BRIAN LIN * * *

The following update was received via email: On June 30, 2020, the licensee reported that there had been another failure with the gauge. The Radiation Safety Officer (RSO) was investigating to determine what had happened and learned that the rotary element and the source tube attached to it had come partially out of the gauge and when employees tried to put it back in it came apart into pieces. The two employees thought the source was still in the gauge housing and they picked up the pieces. They did not realize that one of the pieces they picked up was the source and it had separated from the source tube. One employee picked it up and gave it to the other employee who put it into his shirt pocket. The RSO contacted a licensed service company who put the source into a lead pig and it is now secured at the licensee's facility. The licensee is continuing to investigate, but initial dose calculations as of July 1, 2020 indicate the dose, especially to the one employee, will exceed reporting requirement of greater than 25 rem TEDE (Total Effective Dose Equivalent). The licensee will conduct a re-enactment to collect better information for dose reconstruction and calculation. They have been given the information for REAC/TS and have indicated they will pursue contacting them for biodosimetry. Current activity for the Cesium-137 source is 95 milliCuries (was 100 milliCi original activity). More information will be provided as it is obtained in accordance with SA-300. Notified R4DO (Silva), NMSS Regional/INES Coordinator (Rivera-Capella) and NMSS Event Notifications (email).

The following information was received from the Texas Department of State Health Services (the Agency) via E-mail: On May 29, 2020, at approximately 0130 (CDT), the licensee notified the Agency that at approximately 2300 (CDT) on May 28, 2020, one of its industrial radiography crews was crossing a river southeast of Fredericksburg, Texas, when their vehicle was washed off the road and into the river. Their SPEC 150 exposure device, containing a 47 curie Iridium-192 source, is secured in the vehicle locked inside a robust overpack container, which is held by locked metal brackets which are bolted to the truck. The two radiographers and two licensee staff who responded, aided by county law enforcement with a helicopter, are looking for the vehicle. The river is flowing full and swift and making their search difficult and the truck appears to be being carried downstream. The roof of the darkroom was seen by helicopter at approximately 0440 (CDT). At this time, it is unlikely that an exposure could result to persons in unrestricted areas. More information will be provided as it is obtained in accordance with SA-300. Notified DHS SWO, DOE Operations Center, FEMA Operations Center, HHS Operations Center, USDA Operations Center, EPA Emergency Operations Center, DHS CISA IOCC Watch Officer, FDA Emergency Operations Center (email), Nuclear SSA (email), FEMA National Watch Center (email) and DNDO Joint Analysis Center (email). Texas Incident No.: I-9722

• * * UPDATE ON 5/30/2020 AT 1924 EDT FROM KAREN BLANCHARD TO BRIAN P. SMITH * * *

The following updated information was received from the Texas Department of State Health Services (the Agency) via E-mail: On May 29, 2020, the pickup was found almost totally submerged approximately 1 mile downstream from where it entered the (Pedernales River at Goehmann Lane southeast of Fredericksburg, Texas). On May 30, 2020, the darkroom, which had separated, intact, from the vehicle, was found approximately 11 miles downstream from where it entered the river. Both were recovered May 30, 2020 by the licensee and will be transported to one of their licensed facilities on May 31, 2020. Neither the exposure device nor the overpack in which it was stored in the darkroom were in the vehicle or darkroom. The licensee has attempted to continue search operations to locate the device, but the river levels and water current are prohibitive at this time. They will continue the search as conditions permit, which will improve as the water recedes. Media and public attention are increasing. The Agency has released and the county will release statements (press releases). Exposure risk is still considered low at this time. In the update email a correction has been made in that the device is an INC IR100 and not a SPEC 150 as previously reported. The source information remains the same. Notified R4DO (Werner), ILTAB (Clark), IRD (Kennedy), INES (Milligan), NMSS (Williams), NMSS Events Notification (email), CNSNS (email)

• * * UPDATE ON 5/31/2020 AT 1933 EDT FROM KAREN BLANCHARD TO BRIAN P. SMITH * * *

The following updated information was received from the Texas Department of State Health Services (the Agency) via email: The device has been found on the riverbank and recovered by the licensee approximately 13 miles from where the truck entered the river. It was still secured inside the overpack container. No exposures to any member of the public. Notified R4DO (Werner), ILTAB (Clark), IRD (Kennedy), INES (Milligan), NMSS (Williams), NMSS Events Notification (email), CNSNS (email), DHS SWO, DOE Operations Center, FEMA Operations Center, HHS Operations Center, USDA Operations Center, EPA Emergency Operations Center, DHS CISA IOCC Watch Officer, FDA Emergency Operations Center (email), Nuclear SSA (email), FEMA National Watch Center (email) and DNDO Joint Analysis Center (email).

• * * UPDATE ON 6/3/2020 AT 0904 EDT FROM KAREN BLANCHARD TO THOMAS KENDZIA * * *

The following updated information was received from the Texas Department of State Health Services (the Agency) via email: GPS coordinate mapping has provided more accurate information on the locations of the truck, darkroom, and industrial radiography device recovery locations. From the bridge where the truck entered the water: the truck was located within 1 mile, the radiography device was approximately 8.5 miles and the darkroom was approximately 9.9 miles. Notified R4DO (Proulx), ILTAB (Clark), IRD (Gott), INES (Milligan), NMSS (Rivera-Capella), NMSS (Williams), NMSS Events Notification (email), CNSNS (email), DHS SWO, DOE Operations Center, FEMA Operations Center, HHS Operations Center, USDA Operations Center, EPA Emergency Operations Center, DHS CISA IOCC Watch Officer, FDA Emergency Operations Center (email), Nuclear SSA (email), FEMA National Watch Center (email) and DNDO Joint Analysis Center (email). 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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

The following was received via E-mail from the State of Texas: On June 23, 2020, the licensee reported that at approximately 0900 CDT, a Medical Event occurred at its facility. The event involved a patient receiving an High Dose Rate (HDR) cervix treatment with a Nucletron Model microSelectron using a tandem and ring. The device contained a 5.191Curie Iridium-192 source. After the treatment was completed and the device was removed, it was discovered the tandem had broken into two pieces. The licensee stated it is unknown where the source was positioned during the treatment. The licensee reported no warnings or errors from the machine were recorded from either the check source or the treatment cable. The licensee stated the source was in the patient for a total of 564.7 seconds. The source was in the tandem a total of 355.2 seconds of that total time. The licensee stated the physician has been notified, but was not sure if the patient had been notified. The licensee stated they were still investigating what occurred and will provide more specific information as it is discovered. Additional information will be provided as it is received in accordance with SA300. Texas Incident No.: 9774

• * * UPDATE FROM ART TUCKER TO DONALD NORWOOD AT 0902 EDT ON 6/30/2020 * * *

The break in the tandem occurred about four inches from the end of the tandem. A picture provided by the licensee shows the break at the beginning of the bend in the tandem on the insertion end at the start of the ring. The licensee stated using the location of the guide wire, which they could track, it now appears that the source tracked next to the tandem and that the exposure occurred only to the intended tissue. The manufacture is investigating the event with the licensee. Additional information will be provided as it is received in accordance with SA300. Notified R4DO (Silva) and NMSS Events Notification E-mail group.

At approximately 1749 CDT on August 1, 2020, the licensee notified the agency (Texas Department of State Health Services) that at approximately 1200 CDT, one of the licensee's technicians had completed density testing and placed the Troxler Model 3440 gauge (SN: 25201) in the bed of his pickup with the insertion rod locked. The technician then collected a moisture sample. He failed to secure the gauge in its transportation case and failed to raise the tailgate of the truck as well. The technician had driven approximately 1.5 miles from the site when he realized what had happened and that the gauge was not in the bed of the truck. He reported immediately to his supervisor. The licensee searched by vehicle and on foot the entire route the technician had driven and also checked with some other workers on the site but they had not seen anything. The licensee reported the loss to local police department and then notified the agency. The licensee will pursue other avenues to attempt to locate the gauge (notify pawn shops, check for surveillance cameras at locations along the route, etc.). The gauge contained an 8 milliCurie cesium-137 and 40 milliCurie americium-241 source. More information will be provided as it is obtained in accordance with SA-300. Texas Incident No.: TBD.

• * * UPDATE ON 8/1/20 AT 2150 EDT FROM KAREN BLANCHARD TO BETHANY CECERE * * *

The licensee has notified the agency (Texas Department of State Health Services) that a member of the public had posted on Facebook that he had found the gauge. The technician who lost the gauge saw the post and made arrangements to get the gauge from him. At approximately 1945 CDT, the licensee took possession of the gauge. The lock on the insertion rod was still in place, sources were in the fully shielded position, and there is no apparent damage to the gauge. The licensee will have it checked by the manufacturer/service company. Licensee will notify LLEA of the recovery. Notified R4DO (Gepford), NMSS Events Notification, ILTAB, and CNSNS (Mexico). 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

EN Revision Imported Date : 8/17/2020 AGREEMENT STATE REPORT - FIRE INVOLVING OIL WELL LOGGING SOURCE On August 13, 2020, the Agency (Texas Department of State Health Services) was contacted by the Nuclear Regulatory Agency (NRC) and notified that they had been contacted by a State of Texas licensee. The NRC still had the licensee on their bridge line and tied the Agency into the call with the licensee. The licensee's radiation safety officer (RSO) reported that one of their well service blending trucks was engaged in a fire. The well is located near Mentone, Texas. The truck has a TN model 5190 nuclear gauge containing a 200 milliCurie cesium - 137 source installed on the piping system. The gauge was purchased in December 2019. At the time of the call (2121 CDT) the fire was still burning, and a fire department was on scene. The RSO believed the fire department was aware of the source. The RSO stated all their personnel had been evacuated from the scene of the fire. There is no way to know the status of the gauge shielding or of the source. The RSO agreed to contact the Agency when the fire was put out, and after completing a survey of the gauge. Additional information will be provided as it is received in accordance with SA-300. TX Incident #: I-9783 Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

• * * RETRACTION ON 8/14/2020 AT 2051 EDT FROM ART TUCKER TO KERBY SCALES * * *

The following retraction was received from the state of Texas via email: On August 14, 2020, the licensee reported that after the fire was extinguished it found that the fire did not reach the gauge or equipment around it. This included electrical wiring and rubber hoses which showed no damage from the fire. A portion of the equipment the gauge was mounted to did have some fire damage. An Agency radioactive material inspector went to the site and performed a dose rate survey on the gauge. Based on this survey, it does not appear there was any damage to the gauge shielding. There was a second gauge at the site, but it was not anywhere near the area of the fire and was not affected. It was also surveyed and did not appear to have had any damage. The dose rates taken on the gauges were similar. Based on this information this event does not meet the reporting criteria and is therefore retracted. The licensee has performed a leak test of the gauge and if the results are greater than the limit it will be reported in accordance with SA-30. Notified R4DO (Proulx), NMSS EO (Williams), IRD MOC (Gott), and NMSS Event Notifications (email). Additionally notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

EN Revision Imported Date : 9/1/2020 AGREEMENT STATE REPORT - LOST SHIPMENT OF TRITIUM EXIT SIGNS The following was received from the Texas Department of State Health Services (the Agency) via email: On August 28, 2020, the Agency was contacted by an individual to notify it that they had shipped seven Forever Lite tritium exit signs to a manufacturer in May of 2020 and they have been informed by the transportation company that they do not know where the signs are. The signs are Forever Lite signs, each containing 7.03 curies (original activity) of tritium, manufactured in May 2011. The package was last scanned in Fort Worth, Texas, in May of 2020. The shipper stated that they were told on May 19, 2020 it was to be delivered in Canada. The next update when they followed up they were advised the package was lost and they were trying to locate the shipment and opened a claim. The location where the signs were lost is unknown at this time; therefore, the Agency is making this report for your information. The Agency has requested additional information and clarifications from the shipper. Additional information will be provided as it is received. Texas Incident #: I - 9789 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

• * * UPDATE ON AUGUST 31, 2020 AT 1126 EDT FROM ART TUCKER TO BRIAN LIN * * *

The following was received from the Texas Department of State Health Services (the Agency) via email: After reviewing documents provided by the licensee, the Agency contacted the licensee and confirmed that eight signs were lost and not seven as previously reported. The transportation company's radiation safety officer (RSO) was contacted by the Agency and the RSO stated they do not store the tracking records of shipments in their computer system for very long, therefore they would not be able to review the tracking information for this shipment. The Agency will provide additional information as it is received in accordance with SA-300. Notified R4DO (Deese), NMSS Events Notification, ILTAB, CNSC (Canada), and CNSNS (Mexico) via email.

EN Revision Imported Date : 10/9/2020 AGREEMENT STATE REPORT - LOST AND FOUND DEVICE The following information was submitted by the Texas Department of Health Services (the Agency) via email: On September 15, 2020, at 1700 CDT, the Agency was notified by the licensee's radiation safety officer (RSO) that one of their technicians had left a Troxler model 4640B density gauges at a job site overnight. The technician had completed their work on September 14, 2020, and left the job site after completing their paperwork, but failed to store the device into their truck. The RSO stated the gauge handle was locked and did not believe any individual would receive an exposure. The RSO stated the device contains two cesium-137 sources, but did not know the activities. The manufacturer's website states the activity to be 8 (+ or - 1) milliCuries. The licensee's license states a device source cannot exceed 9 milliCuries. The RSO stated they had technicians out searching for the gauge. At 1736 CDT, on September 15, 2020, the RSO contacted the Agency and reported the gauge had been recovered. He could not provide any additional information. Additional information has been requested. If during the investigation of this event it is determined that an individual could have been exposed, the Agency will submit an update to this report. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: 9797

• * * UPDATE ON 10/08/2020 AT 0749 EDT FROM ART TUCKER TO OSSY FONT * * *

The following update was received from the Agency via email: On October 7, 2020, the Agency was notified by the licensee that the gauge only had one source and not two as first reported. The licensee stated it thought it had two sources because of the way it calculates the density of the top two inches. The licensee stated it has only one source, but two detectors so it can calculate thin lift density. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Josey) and NMSS Events Notification and ILTAB via email.

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