ENS 52346

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v t e ENS Event
07:00 Nov 1, 2016
Title	Agreement State Report - Unable to Retract Source on Nucletron Microselectron
Event Description	The following is an excerpt of a report received from the Oregon Department of Health via email: [The Oregon Department of Health] had a teleconference with the Radiation Safety Officer (RSO). [The RSO] stated that during the morning QA check, the source would not retract. No patient was in the room and the QA check was performed with no one in the room. The RSO went inside the room just at the door and obtained an exposure [rate] reading of 2.6 mR/hr at approximately 15 feet from the HDR [high dose rate] unit, a Nucletron model microSelectron 106.990. The treatment room is secured at the current time until the Elekta FSE [Field Service Engineer] arrives. The RSO is working on treatment of another patient and will get more information as he gets time to do so. During a phone call with the Elekta RSO, the Elekta RSO stated that the FSE found that the HDR unit [obstruction alarm] was being tested during QA by locking the HDR exit port [in order to block the source] and [cause an] alarm condition. The port was only partially locked so that the source was able to get out but not able to retract. The FSE was able to retract the source by opening the port fully and didn't have to manually do it. Total dose received was estimated at 10 mR maximum. The Elekta RSO mentioned that there could be shavings from the sealed source capsule around the port and that leak tests have been negative but that the entire HDR head, including source is now to be replaced. Device: Nucletron Model: microSelectron 106.990 Activity: Ir-192, 10 Ci. Oregon Incident Number: OR160004

ENS 52346 +/-
Where
Oncology Associated Of Oregon Eugene, Oregon (NRC Region 4)
License number:	90862
Organization:	Or Dept Of Health Rad Protection
Reporting

Agreement State
Time - Person (Reporting Time:+78.08 h3.253 days <br />0.465 weeks <br />0.107 months <br />)
Opened:	Todd S Carpenter 13:05 Nov 4, 2016
NRC Officer:	Jeff Herrera
Last Updated:	Nov 4, 2016
52346 - NRC Website
v • d • e

v t e Emergency Notification System
Oncology Associated Of Oregon with Agreement State
WEEKMONTHYEAR2016-11-01T07:00:00 [Table view]
[ENS list for Oncology Associated Of Oregon]

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