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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 41853 | 6 January 2005 13:00:00 | 10 CFR 21.21 | Part 21 Notification Concerning Malfunction of a High Dose Rate Brachytherapy Remote Afterloader Device | The RSO at the Rapid City Regional Hospital reported a malfunction of a high dose rate brachytherapy remote afterloader manufactured by Nucletron - Old Delft (Headquarters in Maryland). The unit was a Microselect V-2 with 18 channels. While treating a patient, the source had been deployed successfully through 16 channels. When attempting to deploy the source into the 17th channel, an alarm was received indicating a problem and locked-out the source in its safe shielded position. Attempts to correct the problem were unsuccessful and the treatment was terminated. No excess exposure resulted from the problem. A service representative from Nucletron serviced and repaired the device on January 7, 2005. The "Flag" wire on the device was determined to be broken and the "V" block was replaced. The device flag is a component that monitors the position of the source and will lock out the device when it does not respond properly. It was noted by the RSO that the device had been in service for about 5 years without any problem of this nature. This problem was discussed with NRC Region 4 inspector (Rick Munoz) on 7/13/05 during a routine inspection of the hospital. Additional discussions were conducted with NRC HQ (Greg Morell) on 7/19/05. The hospital RSO will followup this verbal notification with a written report. |