On the morning of August 18, 2015, the Elekta Field Service Engineer (FSE) was called to the [Customer's facility, McLaren Cancer Institute Macomb, in Mt. Clemens, MI] to investigate an obstruction error involving a 10.2 Ci
Ir-192 source and a Flexitron
HDR. The facility was using a microSelectron source position check ruler to check the source positioning of the Flexitron source. The source became lodged in the check ruler. The system E-stop was unable to retract the source.
The FSE placed the check ruler and stuck source assembly into the customer's microSelectron HDR (mHDR) Emergency Service container (ESC) in order to secure the radioactive material in a shielded container. He then tried to manually retract the source back into the Flexitron unit which was also unsuccessful.
Elekta RSO [Radiation Safety Officer] and FSE engaged the assistance from Senior Technical Support in Veenendaal [Netherlands]. After several troubleshooting attempts, the final decision was to remove the source tail in its entirety from the Flexitron unit. During the whole process, the source cable, check ruler and transfer tube remained secured in the emergency service container.
Currently, the customer's mHDR ESC, which contains the source cable assembly, is secured and being bunkered inside the facility's 'dog house.' The survey readings of the ESC obtained by the customer physics staff were 50 mR/hr at the surface hot spot and 18 mR/hr at 1 meter.
The FSE has checked the mechanical condition of the Flexitron unit and has loaded a dummy source. The unit is functioning properly.
Elekta has reached out to their source manufacturer for assistance in transporting the source assembly in its entirety out of the facility.
Elekta has escalated this case to the complaint handling department at Elekta/Nucletron B.V. for investigation. Further information will be forwarded upon receipt.
There were no over exposures or contamination involved with this event.
- * * UPDATE AT 1331 EDT ON 08/19/15 FROM PRAVEEN DALMIA OF MT. CLEMENS REGIONAL MEDICAL CENTER TO JEFF HERRERA * * *
This event was reported by Mt. Clemens Regional Medical Center d/b/a McLaren McComb, Mt. Clemens, MI. NRC License No. 21-04080-01 - See EN 51341
Notified R1DO (DeFrancisco), R3DO (Riemer) and
NMSS Events Notification Group via email.