On the evening of 12/2/08, Varian, a service contractor, had completed a successful source exchange on a Nordion GammaMedPlus
Brachytherapy device, serial # H600447. That same evening, the new source wire became jammed during the third position verification test procedure. The source would not retract using the electronic devices provided on the machine. The source was manually retracted to the shielded position by a service technician within a few minutes of the event. The source, cable, and associated equipment have been removed from the device. They have been packaged for shipment to the manufacturer in England for further examination. The dose estimate to retract the source to the safe position is approximately 35 millirem. The source was a 9.12 curie
Iridium (Ir) - 192 source model # VS2000. The source serial number was not available. The source is currently stored in a transportation container. The manufacturer believes that a small piece of debris prevented the source from fully retracting.
The licensee stated that they will provide the state with a written report by 12/9/08. Additional information will be forwarded to the NRC as it is received.
Texas Incident Number: I-8586
- * * UPDATE FROM ART TUCKER TO JOE O'HARA AT 0953 ON 12/5/08 * * *
The following was provided from the state via e-mail:
The Radiation Safety Office for Varian Medical Systems Inc. contacted the [Texas Department of State Health Services] Agency and stated that the device involved was a VariSource Brachytherapy HDR Remote Afterloader (SSD # CA-0661-D-103-S) and not a Nordion GammaMedPlus Brachytherapy device. All other information is correct.
Notified R4DO (Proulx) and
FSME (Einberg)