Event Notification Report for December 04, 2024

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION

The following report was received by the Texas Department of State Health Services (the Department):

"On 11/26/24, the Department was notified by the licensee of a malfunction that occurred with one of its cameras during an industrial radiography procedure. The licensee stated that a technician, while operating a SPEC 150 camera containing a 56 curie source of Ir-192, heard grinding noises during the crank-out process. The technician then retracted the source and conducted a source survey to confirm that it had returned to the shielded position. Upon inspection, the technician observed that the source was still extended at the end of the guide tube. The technician contacted the radiation safety officer (RSO), who responded to the scene, conducted an inspection, and was unable to determine if the source had become disconnected. The RSO subsequently covered the source with lead shielding and contacted the manufacturer who advised the licensee to transport the camera and source to the manufacturer for further examination and repair.

"The licensee stated no members of the public were exposed to radiation because of the incident.

"Additional information will be provided in accordance with SA-300."

Texas Incident Number: 10147
Texas NMED Number: 240046

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

The following information was provided by the Illinois Emergency Management Agency (The Agency) via email:

"The Agency was contacted the evening of 11/26/24 by the radiation safety officer for Princeton Technical Services to advise that a Troxler 3430 moisture density gauge had been hit by a vehicle while in use at the airport. Reportedly, the authorized user (AU) set the portable gauge next to his vehicle and forgot to properly secure it prior to moving. The vehicle struck the gauge and broke off the face plate and the electronic keypad. The AU stated that there was no damage to the source housings and the cesium source rod was fully retracted. These statements were confirmed by on scene Chicago Fire Department (CFD) personnel. The CFD used a Thermo RadEye device to measure the exposure rate at one meter which was compared to the shipping papers. The reading at one meter was 189 microR/hour and the listed transport index was 0.3 which supports the fact that the source rod was properly shielded. The gauge was then packaged in the undamaged case and transported back to the licensee's location.

"Agency inspectors conducted a reactive inspection the morning of 11/27/24 and corroborated the details above. The licensee's written report is pending and will be used to update this event with a root cause and corrective actions. The licensee attributes the cause of the event to human error and the failure to follow their procedure."

Illinois Item Number: IL240029
Source Number: 1
Source/Radioactive Material: Sealed Source Gauge
Manufacturer: AEA Technologies
Model Number: NR
Serial Number: 750-9439
Radionuclide: Cs-137
Activity: 0.008 Ci (8 mCi or 296 MBq)
Source Number: 2
Source/Radioactive Material: Sealed Source Gauge
Manufacturer: Isotope Products Lab
Model Number: NR
Serial Number: 47-6362
Radionuclide: Am-Be
Activity: 0.04 Ci (40 mCi or 1.48 GBq)

AGREEMENT STATE REPORT - DAMAGED DENSITOMETER

The following report was received by the New Mexico Radiation Control Program (the Program) via email and phone:

"The Program reported that a Berthold densitometer, model number 'LB8010', serial number '12133', Cesium-137 source with an activity of 20 mCi, had a shutter handle failure while on a fracking operation near Jal, New Mexico. The pad name is the Matador Firethorn. The device was not physically damaged, but the shutter handle became detached from the device. The failure is being considered a design failure on the Berthold device. The shutter is in the open position and cannot be closed. The vendor in Houston, Texas, has been requested to come to the location and change out the device for one that is operable. The vendor has been requested to transport the device back to Houston in preparation for disposal.

"There were no unnecessary exposures to any persons as a result of this incident."

FALSE NEGATIVE QUALITY ASSURANCE TEST

The following information was provided by the licensee via phone and email:

"Contrary to the requirements in 10 CFR 26.137(b), a Health and Human Services (HHS) certified laboratory returned a blind specimen result that was inconsistent with what was expected.

"On November 14, 2024, blind specimens from the same lot number were sent to the two contracted HHS laboratories. On November 27, 2024, one of the labs reported unexpected results while the other laboratory reported the expected results (positive for opiates). At approximately 1415 CST on December 3, 2024, the lab report was reviewed by the fitness-for-duty medical review officer (MRO) staff at the South Texas Project and the inaccurate result was identified. At approximately 1510 CST on December 3, 2024, MRO staff contacted the laboratory to discuss the testing discrepancy and directed the lab to retest the specimen. The MRO staff also requested that the laboratory initiate an investigation to determine the reason for the inaccurate result.

"10 CFR 26.719(c)(3), reporting requirements state, 'If a false negative error occurs on a quality assurance check of validity screening tests, as required in  26.137(b), the licensee or other entity shall notify the NRC within 24 hours after discovery of the error.'

"The licensee has notified the NRC Resident Inspector."