ENS 53161

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v t e ENS Event
05:00 Jan 9, 2018
Title	Agreement State Report - Source Cable Damaged in High Dose Rate Afterloader Unit
Event Description	The following information was received via E-mail: On January 9, 2018, the licensee informed the Department [Pennsylvania Department of Environmental Protection] of a problem with their Flexitron HDR [high dose rate] unit. It is reportable per 10 CFR 30.50(b )(2). After a service provider completed a source exchange on an Elekta Flexitron Model 136149A02 HDR remote afterloader unit containing 9.6 curies of iridium-192 on Friday morning, January 5, 2018, the unit was tested for operation three times and worked properly. At approximately 1400 EST on the January 5, 2018, a hospital physicist was starting his QA procedures on the unit. At that point, the source would not come out of the safe position and he received an error code. The physicist then contacted the service provider and he returned to the site. The service provider tried multiple tasks to get the source to engage, all were unsuccessful. He felt there was some form of obstruction or possibly a drive issue. He then scheduled to be onsite January 9, 2018 with a fellow engineer to further investigate the issue. They discovered the source cable was badly frayed and could not be safely removed and placed into the existing transport containers. Currently, the source and cable have been taped in place so they will not move and the device has been locked in its storage closet at the facility. The Department is in contact with the hospital Radiation Safety Officer and further information is not available at this time. The Department will perform a reactive inspection. More information will be provided as received. PA Event Report ID No: PA180001

ENS 53161 +/-
Where
West Penn Hospital Pittsburgh, Pennsylvania (NRC Region 1)
License number:	PA-0121
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+30.92 h1.288 days <br />0.184 weeks <br />0.0424 months <br />)
Opened:	John Chippo 11:55 Jan 10, 2018
NRC Officer:	Donald Norwood
Last Updated:	Jan 10, 2018
53161 - NRC Website
v • d • e

v t e Emergency Notification System
West Penn Hospital with Agreement State
WEEKMONTHYEAR2018-01-09T05:00:00 [Table view]
[ENS list for West Penn Hospital]

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