ENS 46264

v t e ENS Event
02:00 Sep 21, 2010
Title	High Dose Rate Afterloader Stuck / Exposed Source
Event Description	On 9/20/10, the licensee was having scheduled maintenance work performed on a Varian High Dose Rate (HDR) afterloader. A source exchange was also scheduled to be performed. During the source exchange, the source became "stuck, partially exposed, not fully shielded in the shield" of the HDR machine and became inoperable. The licensee believes this to be due to personnel error on the part of the service technician. The service technician then vacated the room. Varian was called and said they would dispatch personnel to the hospital on 9/21/10. Security was notified of the radiation safety problem. The door to the room was secured. The door to the room was posted with hazard warning tape, with a do not enter sign, and with a high radiation area sign. The department was also locked down. Varian personnel arrived on-site on 9/21/10. Varian service personnel secured the source back in the machine. Radiation levels in the room then returned to normal background readings. The source wire was found kinked and shipped out today. The hospital is scheduled to receive a new source and have it installed tomorrow. Service personnel were wearing "active monitors" and received only a few milli-rem during the repair operation. It is not known at this time how much dose the first service technician received.

ENS 46264 +/-
Where
Southeast Missouri Hospital Cape Girardeau, Missouri (NRC Region 3)
License number:	24-00128-03
Organization:	Southeast Missouri Hospital
Reporting

10 CFR 30.50(b)(2), Licensed Material Protection Equipment Failure
Time - Person (Reporting Time:+16.37 h0.682 days <br />0.0974 weeks <br />0.0224 months <br />)
Opened:	Sam Hancock 18:22 Sep 21, 2010
NRC Officer:	Donald Norwood
Last Updated:	Sep 21, 2010
46264 - NRC Website
v • d • e

v t e Emergency Notification System
Southeast Missouri Hospital with 10 CFR 30.50(b)(2)
WEEKMONTHYEAR2010-09-21T02:00:00 [Table view]
[ENS list for Southeast Missouri Hospital]

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