ENS 41853

v t e ENS Event
13:00 Jan 6, 2005
Title	Part 21 Notification Concerning Malfunction of a High Dose Rate Brachytherapy Remote Afterloader Device
Event Description	The RSO at the Rapid City Regional Hospital reported a malfunction of a high dose rate brachytherapy remote afterloader manufactured by Nucletron - Old Delft (Headquarters in Maryland). The unit was a Microselect V-2 with 18 channels. While treating a patient, the source had been deployed successfully through 16 channels. When attempting to deploy the source into the 17th channel, an alarm was received indicating a problem and locked-out the source in its safe shielded position. Attempts to correct the problem were unsuccessful and the treatment was terminated. No excess exposure resulted from the problem. A service representative from Nucletron serviced and repaired the device on January 7, 2005. The "Flag" wire on the device was determined to be broken and the "V" block was replaced. The device flag is a component that monitors the position of the source and will lock out the device when it does not respond properly. It was noted by the RSO that the device had been in service for about 5 years without any problem of this nature. This problem was discussed with NRC Region 4 inspector (Rick Munoz) on 7/13/05 during a routine inspection of the hospital. Additional discussions were conducted with NRC HQ (Greg Morell) on 7/19/05. The hospital RSO will followup this verbal notification with a written report.

ENS 41853 +/-
Where
Rapid City Regional Hospital Rapid City, South Dakota (NRC Region 4)
License number:	40-00238-04
Organization:	Rapid City Regional Hospital
Reporting

10 CFR 21.21
Time - Person (Reporting Time:+4655 h193.958 days <br />27.708 weeks <br />6.376 months <br />)
Opened:	Ed Cytacki 11:00 Jul 19, 2005
NRC Officer:	Bill Huffman
Last Updated:	Jul 19, 2005
41853 - NRC Website
v • d • e

v t e Emergency Notification System
Rapid City Regional Hospital with 10 CFR 21.21, Notification of failure to comply or existence of a defect and its evaluation
WEEKMONTHYEAR2005-01-06T13:00:00 [Table view]
[ENS list for Rapid City Regional Hospital]

Navigation menu