ENS 56383

v t e 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

ENS 56383 +/-
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
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v t e Emergency Notification System
Citizens Medical Center with Agreement State
WEEKMONTHYEAR2023-02-27T06:00:00 [Table view]
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