ENS Event | |
|---|---|
06:00 Feb 27, 2023 | |
| Title | Stuck Source |
| Event Description | The following information was provided by the Texas Department of State Health Services (the Agency) via email:
On February 27, 2023, the Agency was sent a reciprocity notice that a service company was going to work in a hospital to repair a Elekta model 136146 Flexitron high dose rate remote afterloader unit (HDR) containing 10 Ci of Ir-192. The report indicated the source was stuck. The Agency contacted the hospital and determined that the source became stuck outside the HDR unit during the conduct of a dwell position accuracy check using the source position check ruler. This was conducted as a daily Quality Assurance (QA) check. The QA device transfer tube for the test was connected upside down, the connector was inverted, by error, which allowed the source to travel outside the tube and get stuck outside the vault below the ruler. The source could not be retrieved. There is no report of excess exposure to hospital staff and no medical procedure was being conducted. The unit was repaired and a report was issued by the service technician to determine if there is a design issue with the test equipment. Additional details will be sent in accordance with SA 300. Texas Incident Number: I-9994 Texas NMED Number: TX23007 |
| Where | |
|---|---|
| Citizens Medical Center Victoria, Texas (NRC Region 4) | |
| License number: | L 00283 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+25.03 h1.043 days <br />0.149 weeks <br />0.0343 months <br />) | |
| Opened: | Chris Moore 07:02 Feb 28, 2023 |
| NRC Officer: | Adam Koziol |
| Last Updated: | Feb 28, 2023 |
| 56383 - NRC Website | |
Citizens Medical Center with Agreement State | |
WEEKMONTHYEARENS 563832023-02-27T06:00:00027 February 2023 06:00:00
[Table view]Agreement State Stuck Source 2023-02-27T06:00:00 | |