ENS 44774

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v t e ENS Event
05:00 Jan 14, 2009
Title	Part 21 Report Due Potential Issue of Afterloader Source Sticking
Event Description	The active source may have movement difficulties and become stuck during source extension or retraction. The problem may occur with the source outside of the HDR unit's tungsten shield. This type of event was first seen in December 2008. This event has occurred three times: "a) Southwest Regional Cancer Center, Austin TX - December 2, 2008 [see EN #44697] "b) Hershey Medical Center, Hershey PA - December 11, 2008 c) Stanford University Medical Center, Stanford, CA - December 30, 2008 In each case the problem occurred during a routine source exchange and patients were not involved. The emergency retract handle was used in each occurrence to retract the source and park it safely in the HDR unit's tungsten shield. The relationship between the source exchange and the problem is unknown. The affected sites in the United States are as follows: St. Joseph's - Mercy Hospital of Macomb - Clinton Twp., MI Cancer Healthcare Associates Cedars Med Ctr - Miami, FL Providence Hospital - Anchorage, AK Coborn Cancer Center - St. Cloud, MN Stanford University Medical Center - Palo Alto, CA Barnes Jewish #2 - Washington University - St. Louis, MO Mayo Clinic - Rochester, MN DeKalb Medical Center - Decatur, GA Cy-Fair Cancer Center - Houston, TX Billings Clinic - Billings, MT Palm Beach Cancer Institute - West Palm Beach, FL St. Lukes - Bethlehem, PA University of Nebraska Medical Center - Omaha, NE Geisinger Health System - Wilkes-Barre, PA Southwest Regional Cancer Center - Austin, TX Hershey Medical Center - Hershey, PA Carolinas Medical Center - Charlotte, NC Cheyenne Regional Medical Center - Cheyenne, WY Mary Washington Hospital - Fredericksburg, VA Treasure Coast Radiation Oncology - Stuart, FL Mayhill Denton Cancer Center - Denton, TX Hamilton Medical Center - Dalton, GA Providence Hospital - Everett, WA Good Samaritan Hospital - Downers Grove, IL Seattle Cancer Care Alliance - Seattle, WA * * UPDATE FROM RICHARD PICCOLO TO JASON KOZAL AT 1240 ON 01/15/09 * * * After conferring with Region 1 (Gabriel) and NRC HQ (Flannery) the licensee is also reporting this under 10 CFR 30.50(b)(2). Notified R1DO (Burritt) and FSME (Flannery).

ENS 44774 +/-
Where
Varian Medical Systems Charlottesville, Virginia (NRC Region 1)
Organization:	Varian Medical Systems
Reporting

10 CFR 21.21 10 CFR 30.50(b)(2), Licensed Material Protection Equipment Failure
Time - Person (Reporting Time:+11.63 h0.485 days <br />0.0692 weeks <br />0.0159 months <br />)
Opened:	Richard G. Piccolo 16:38 Jan 14, 2009
NRC Officer:	Jason Kozal
Last Updated:	Jan 15, 2009
44774 - NRC Website
v • d • e

v t e Emergency Notification System
Varian Medical Systems with 10 CFR 30.50(b)(2), 10 CFR 21.21
WEEKMONTHYEAR2014-10-29T17:30:00 [Table view]
[ENS list for Varian Medical Systems]

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ENS Notification