Event Notification Report for September 26, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/25/2023 - 09/26/2023
Agreement State
Event Number: 56761
Rep Org: Texas Dept of State Health Services
Licensee: PRO INSPECTION INCORPORATED
Region: 4
City: Odessa State: TX
County:
License #: L06666
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Ernest West
Licensee: PRO INSPECTION INCORPORATED
Region: 4
City: Odessa State: TX
County:
License #: L06666
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Ernest West
Notification Date: 09/27/2023
Notification Time: 18:40 [ET]
Event Date: 09/26/2023
Event Time: 10:00 [CDT]
Last Update Date: 09/28/2023
Notification Time: 18:40 [ET]
Event Date: 09/26/2023
Event Time: 10:00 [CDT]
Last Update Date: 09/28/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Fisher, Jennifer (NMSS DAY)
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Fisher, Jennifer (NMSS DAY)
AGREEMENT STATE - RADIOGRAPHY SOURCE DISCONNECTED
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
* * * UPDATE ON 9/28/2023 AT 1832 EDT FROM RANDALL REDD TO BETHANY CECERE * * *
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.
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
* * * UPDATE ON 9/28/2023 AT 1832 EDT FROM RANDALL REDD TO BETHANY CECERE * * *
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.
Agreement State
Event Number: 56778
Rep Org: Texas Dept of State Health Services
Licensee: Covestro LLC
Region: 4
City: Baytown State: TX
County:
License #: 01577
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Karen Cotton-Gross
Licensee: Covestro LLC
Region: 4
City: Baytown State: TX
County:
License #: 01577
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/05/2023
Notification Time: 12:53 [ET]
Event Date: 09/26/2023
Event Time: 00:00 [CDT]
Last Update Date: 10/05/2023
Notification Time: 12:53 [ET]
Event Date: 09/26/2023
Event Time: 00:00 [CDT]
Last Update Date: 10/05/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - FIXED GAUGE STUCK SHUTTER
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On October 5, 2023, Covestro LLC (the licensee) reported to the Agency that on September 26, 2023, during routine 6-month checks, the shutter on one of its VEGA SHLG-1 fixed nuclear gauges, containing 1.5 curies cesium-137, was found stuck in the open position. Open is the normal operating position for this gauge. There were no [personnel] exposures and none are anticipated as the gauge is mounted on the side of a vessel and secured from access. The licensee has contacted the manufacturer and is trying to make arrangements for repair or replacement. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: 10056
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On October 5, 2023, Covestro LLC (the licensee) reported to the Agency that on September 26, 2023, during routine 6-month checks, the shutter on one of its VEGA SHLG-1 fixed nuclear gauges, containing 1.5 curies cesium-137, was found stuck in the open position. Open is the normal operating position for this gauge. There were no [personnel] exposures and none are anticipated as the gauge is mounted on the side of a vessel and secured from access. The licensee has contacted the manufacturer and is trying to make arrangements for repair or replacement. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: 10056