ENS 54965

v t e ENS Event
05:00 Oct 20, 2020
Title	Equipment Failed to Function as Designed
Event Description	The following information was received from the State of Wisconsin, Department of Health Service (DHS) via email: On October 20, 2020, the licensee's high dose-rate remote afterloader experienced multiple abnormalities during the administration of a fraction to a patient. Prior to exposure, the device failed to retract its check cable when performing the pre-administration routine. Following the manufacturer's advice, the licensee restarted, and performed a system restore on the device. The routine was then re-initiated and went as expected, with the exception of "Status - Terminated" appearing on the console during the administration. All indications were that the fraction was delivered successfully to the patient. Following the fraction, no information was saved indicating that any fraction had been delivered. The licensee was able to replicate circumstances using radiographic film, and verified that while dose is being delivered as intended, no record is being retained by the software. The licensee worked with a manufacturer's service technician on October 21 to address the issue. They believe they have resolved the immediate hardware and software issues. The manufacturer will continue to follow up on the event. DHS will follow up with the licensee. WI Incident No.: WI200007

ENS 54965 +/-
Where
Columbia - St. Mary'S, Inc. Milwaukee, Wisconsin (NRC Region 3)
License number:	079-1297-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+36.6 h1.525 days <br />0.218 weeks <br />0.0501 months <br />)
Opened:	Kyle Walton 17:36 Oct 21, 2020
NRC Officer:	Brian Lin
Last Updated:	Oct 21, 2020
54965 - NRC Website
v • d • e

v t e Emergency Notification System
Columbia - St. Mary'S, Inc. with Agreement State
WEEKMONTHYEAR2020-10-20T05:00:00 [Table view]
[ENS list for Columbia - St. Mary'S, Inc.]

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