ENS 41579

v t e ENS Event
05:00 Apr 6, 2005
Title	10 Cfr Part 21 Report Involving Potential Defect in an High Dose Rate Afterloading Device
Event Description	Lankenau Hospital reported an incident involving a Nucletron V2 microselectron High Dose Rate Afterloading device. The Hospital reports that a source stuck in a GYN transfer tube during quality operational checks. The source had to be manually retracted with a hand crank back into a safe position. Inspection of the GYN tube revealed a restriction (described as an edge) that developed on the end that connects to the treatment unit. The Hospital report states that the tube had been in use for two years and may have developed the restriction from normal wear and tear. The tube was replaced and the defective tube transferred to Nucletron. The Hospital report notes that normal wire transfer checks (without the source present) did not identify the problem - but probably should have. The Hospital report also stated that the restriction should not have prevent the source from being automatically retracted to its safe location once the emergency stop was actuated. The cause of the GYN tube restriction is unknown.

ENS 41579 +/-
Where
Lankenau Hospital Wynnewood, Pennsylvania (NRC Region 1)
Organization:	Lankenau Hospital
Reporting

10 CFR 21.21
Time - Person (Reporting Time:+60.3 h2.513 days <br />0.359 weeks <br />0.0826 months <br />)
Opened:	Nathan Anderson 17:18 Apr 8, 2005
NRC Officer:	Wesley Held
Last Updated:	Apr 8, 2005
41579 - NRC Website
v • d • e

v t e Emergency Notification System
Lankenau Hospital with 10 CFR 21.21, Notification of failure to comply or existence of a defect and its evaluation
WEEKMONTHYEAR2005-04-06T05:00:00 [Table view]
[ENS list for Lankenau Hospital]

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