The following report was provided by the
Virginia Department of Health via facsimile:
On May 4, 2015, a transportable HDR [high dose rate] unit (Elekta microSelectron Model 106.900, serial number 14514) licensed for use by a Virginia licensee was damaged while being unloaded from its transport trailer. The source activity at the time was approximately 8 curies of IR-192. The damage appeared to be limited to the unit's covers. The licensee contacted Elekta, Inc., (which performs work in Virginia under reciprocal recognition of its Georgia license) and a field service engineer was sent to investigate. The service engineer found the head covers and collar cover were broken and other damages, but tests indicated the unit functioned properly. New covers were ordered. During the following week the source was uploaded into an emergency container while the covers were replaced. After the source was returned to the HDR it was found to be stuck in the safe. A kink was found in the cable and a new source was ordered. A source exchange was scheduled on May 19th, but the source could not be manually unloaded as before. Instead, it had to be removed from the back of the HDR. The frayed cable was cut and the source was placed in the emergency container by the service engineer. The source fell to the bottom of the emergency container and the service engineer could not retrieve it. The container was placed in storage at the Virginia licensee's facility after additional shielding was placed around it to reduce the exposure rate to 200 microR/hour. The dose received by the service engineer as a result of the event was estimated by Elekta, using a worst case scenario, as 327 mrem whole body. The service engineer's dosimeter was sent to the dosimetry supplier for an emergency evaluation. Elekta has contacted the source manufacturer (Alpha-Omega Services) [AOS] to assist in the retrieval of the source from the emergency container and to send it to AOS for further investigation. Elekta will provide additional information as it investigates the event.
Virginia Event Report ID No.: VA-15-06