Event Notification Report for March 24, 2025

EN Revision Imported Date: 3/24/2025

EN Revision Text: AGREEMENT STATE REPORT - LOST/FOUND GAUGE

The following information was received from the Washington State Department of Health (the Department) via email:

"On March 7, 2025, at 1613 PDT, the Department was notified that a portable gauge (Troxler 3411-B) had fallen from a vehicle. This notification initially came from the Washington State Emergency Operations Officer of the Washington Military Department. The notification stated that the licensee had submitted a police report and was actively searching for the source.

"At 1633, the Department Emergency Response Duty Officer (ERDO) forwarded the notification to the Radioactive Materials Section Manager. At 1711, the Materials Section Manager contacted the licensee by phone to determine the scope of response necessary. The licensee informed the Department that the gauge was contained in a locked box and was believed to be lost or stolen. The licensee called back at 1716, informing the Department that the gauge had been found with the box locked, intact, and no signs of damage to the source contained within the shielded gauge. The gauge was found along the side of the road, in a ditch and away from any pedestrian traffic. No exposure is believed to have occurred to the public when considering the source was in a shielded position and inside of a locked Troxler class A container.

"The source was verified to be intact and sealed. Operational verifications of the gauge were performed, and the gauge is functioning normally. The gauge is in the possession of the licensee.

"A final report will be submitted to the NRC after the licensee has responded with corrective actions."

Washington Incident Number: WA-25-005

* * * UPDATE ON 3/21/2025 AT 1947 EDT FROM DANE BLAKINGER TO TENISHA MEADOWS * * *

The following information was received from the Washington State Department of Health (the Department) via email:

"The licensee corrective actions include mandatory retraining of gauge handling and locking procedures for all gauge users at Terra Associates Inc., an increased [frequency] of user audits of locking procedures from every 6 months to every 3 months, and GPS trackers installed on all gauge transportation boxes. The Department will review corrective actions during future inspections, to include a review of this report and ensure licensee is demonstrating compliance with proposed corrective actions."

Notified R4DO (Bywater) and NMSS Events Notification (email)

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the New Mexico Environment Department, Radiation Control Bureau via email:

"The New Mexico Environment Department, Radiation Control Bureau was informed of a medical event at approximately 1605 MDT on Friday, March 14, 2025.

"Incident date: March 4, 2025. Discovery date: March 14, 2025.

"Lovelace Medical Center, license number (MI210)
"Prescribed Activity: 0.5 GBq
"Delivered Activity: 0.4 GBq
"Percent Delivered: -20 percent
"Possible cause: low dose prescribed and/or possible issues with the catheter.

"The facility stated they are working on the 15-day report."

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.

AGREEMENT STATE REPORT - CRIMPED SOURCE GUIDE TUBE

The following information was provided by the California Department of Public Health, Radiologic Health Branch via email:

"A reciprocity licensee, Stronghold Inspection (TX license number L06918), was conducting industrial radiography at a laydown yard located on the Martinez Refining Company site (RML #3590). At about 0200 PDT, a pipe that was being radiographed rolled onto the guide tube of the exposure device (QSA Global 880 Delta, s/n D17238), crimping the guide tube and preventing the 2.73 TBq Ir-192 sealed source (QSA Model 8424-9, s/n 12805P) from retracting into its shielded position. The licensee reports that a perimeter spanning about 200 feet in radius was established. The exposure rate at the perimeter is less than 2 mR/hr and is under constant surveillance. The source is currently located in the collimator at the end of the guide tube. The licensee has requested the assistance of QSA's source retrieval team. Source retrieval is scheduled to begin upon arrival at approximately 1800 PDT. RHB inspectors arrived onsite at about 1000 PDT and will observe the operations until the source has been secured."

California 5010 number: 031425

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:

"On March 17, 2025, the Department received a notification from the licensee regarding the theft of a moisture density gauge. The stolen gauge is a Troxler 3430 containing an 8 mCi Cs-137 sealed source and a 40 mCi Am-241/Be sealed source. The theft is believed to have occurred between 1700 CDT on Saturday, March 15, and 0630 CDT on March 17, 2025. According to the licensee, a technician worked at a scheduled site in Fulshear, Texas on March 15, 2025, but failed to return the gauge to the office for storage. Instead, the technician without approval took the gauge home and left it in the back of a truck. The gauge was stored in its transport container, secured with double locks and placed in the uncovered bed of the truck. The licensee stated that the thieves cut both locks before stealing the gauge in its container. At around 0630 CDT on March 17, 2025, the technician discovered that the gauge had been stolen. The technician immediately reported the theft to the licensee's radiation safety officer and the Houston Police Department. The licensee is currently investigating the matter. The licensee reported that there is no risk of additional radiation exposure to members of the public.

"Additional Information will be provided in accordance with SA300."

Texas Incident Number: I-10183
NMED number: TX250019

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.

AGREEMENT STATE REPORT - DAMAGED SEALED SOURCE

The following information was received from the Illinois Emergency Management Agency (the Agency) via email:

"The Agency was contacted on March 17, 2025, by Alton Steel Inc., to advise of an incident earlier that day in which molten steel overflowed and damaged a 2.3 millicurie Berthold P-2608-100 Co-60 sealed source. Agency staff performed a reactive inspection the same day and determined the damage was limited to the source's pinned-on threaded connector (i.e., not the `active' portion of the source containing the Co-60 wire). Workers appropriately implemented updated emergency procedures, stopped production, isolated the impacted source/mold and notified the radiation safety officer. Extensive Agency surveys and a review of actions taken indicate there were no exposures or site contamination as a result of this incident.

"Both pieces of the source were recovered and placed into secure storage. Shielding was adequate to keep unrestricted areas below 2 mrem per hour. Surveys of the casting mold, the lid, the casting floor, produced billets, and casting remnants evidenced no contamination. The broken piece of the source evidenced no activity, consistent with expectations after a review of the engineering drawings of the source. Due to fouling of the source, the serial number could not be immediately read. A qualified service provider will be contacted to perform leak tests and obtain the source serial number.

"Notably, the licensee has had three similar incidents in which sealed sources were damaged as a result of casting overflows. The root cause is an inherent design issue with the continuous casting molds where severe overflows can penetrate a lubrication circuit and flow directly down the dip tube holding the sealed source. As a result of previous enforcement action, the licensee has completed engineering and prototyping of an improved design which will protect the sealed sources. Agency staff have asked for an expedited timeline and will seek appropriate enforcement action for implementation. Agency action on the license, enabling these changes, will be issued March 18, 2025. Previously identified concerns of personnel exposure and site contamination have been addressed through updated training and new procedures."

Illinois Incident Number: IL250011

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following information was provided by the California Department of Public Health via email:

"On Monday, March 17, 2025, the California State University - Long Beach alternate radiation safety officer reported the loss of one tritium exit sign from their campus' Carpenter Performing Art Center. This exit sign was an Isolite tritium exit sign, made on April 5th, 2015, Model 2000, S/N H50630, with an initial tritium activity of 0.281 TBq (7.6 Ci). The exit sign was officially declared lost on March 14, 2025, after a thorough search by campus environmental health and safety personnel could not locate the exit sign. A contamination survey of the exit sign's designated location did not show the presence of tritium contamination. The licensee will continue to look for the exit sign and provide additional information when available. Corrective actions included refresher training, increased physical inventories of all campus tritium exit signs, and review of methods of securing of exit signs to mounting surfaces."

California 5010 number: 031725

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: 3/24/2025

EN Revision Text: UNABLE TO RETRACT SOURCE

The following is a summary of information provided by Protect, LLC via phone:

At 1043 CDT on 3/21/2025, the radiography crew was unable to retract the source for a radiography camera while performing work at a customer's manufacturing facility in Joplin, MO. The crew went to retract the source into the radiography camera, but the source did not move. The crew established boundaries to limit exposure to less than 2 millirem/hr. The crew notified site personnel and is monitoring the posted boundaries until the source is secured. Additional licensee personnel are enroute to retrieve the source. No personnel exposures due to the malfunction have occurred.

Additional information:
Manufacturer and model number: QSA Global 880
Serial number: A424-9
Source: Ir-192
Activity: 13 Ci

* * * UPDATE ON 03/21/2025 AT 1712 EDT FROM MATT SLAYMAKER TO TENISHA MEADOWS * * *

The following information was provided by Protect, LLC via email:

"On 3/21/2025, Protect, LLC had an industrial radiography source disconnect incident occur while at a customer's manufacturing facility in Joplin, MO. At approximately 1043 CDT, during the crew's first source retraction, it was determined that the source had become disconnected from the drive cable. The crew immediately recognized the situation through the use of their dosimetry equipment and established the emergency 2 millirem/hr boundaries. The regional radiation safety officer (RRSO) was immediately notified of the issue. The RRSO informed the crew to maintain surveillance of the restricted area barricades and to wait until the RRSO and corporate radiation safety officer (CRSO) arrived before any further actions were taken. The CRSO and RRSO arrived at the jobsite at approximately 1340 CDT to retrieve the source. The source was secured back into the exposure device at 1404 CDT. The CRSO received 4.5 millirem during the retrieval procedure and the RRSO received 0.6 millirem.

"Additional information on the manufacturer and model number of equipment involved in the incident:
"QSA Global 880 delta exposure device
"QSA Global Ir-192 source (13 curies), model A424-9
"QSA Global 35 ft control cables
"QSA Global 7 ft extreme weather source tube with a 4 half-value layer (HVL) collimator

"All three personnel on the job are carded radiographers."

Notified R3DO (Havertape) and NMSS Events Notifications (email)