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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 50583 | 29 October 2014 17:30:00 | 10 CFR 30.50(b)(2) | Stuck Source in a Varian High Dose Rate Afterloader | Staff at the New Milford Cancer Center in New Milford, CT were performing their daily quality assurance checks on their Varian Medical Systems high dose rate (HDR) afterloader when the 7.2 Ci (estimated) Ir-192 source became stuck in the safe position. New Milford contacted the vendor who dispatched a support team to investigate. The Varian RSO surveyed the area and found the dose rate at 5 cm was 1.5 mR/hr which was within normal parameters with the source in the shielded position. While attempting to free the source, it became stuck outside of the shielded position. Dose rates increased to 20 mR/hr at the entrance to the maze, 280 mR/hr at the turn (approximately 15 feet from the HDR) and 5.4 R/hr at 0.5 meters. The service manager was able to use the emergency hand crank to return the source to its shielded position. During the retrieval, the RSO received 9 mR while the service manager received 27 mR. Based on past issues and current symptoms, Varian technicians replaced the drive mechanism and will be installing a new source wire. Once all repairs are made, the HDR will be placed into service with the Varian team on hand during the first post-maintenance use. Varian, an NRC licensee, is making this report since New Milford Cancer Center (license number 0617892-01) did not exceed any reporting thresholds due to this event. The vendor has notified R1 (Modes). See similar events in Event Notifications 46695 and 46758. | ||
| ENS 46695 | 23 March 2011 07:00:00 | 10 CFR 30.50(b)(2) | Emergency Retract Mechanism Failure | The Varian equipment representative provided notification of the following event that occurred at the Grady Memorial Hospital in Atlanta, GA. A technician was installing a Varisource IX high-dose afterloader when the active wire composed of a 10 Ci Ir-192 source failed to extend. After troubleshooting it was discovered that the wire was stuck on the wedge block which is part of the emergency retract mechanism. The active wire was removed and the emergency retract mechanism was replaced. The technician received 0.2 mrem during the repair work. | ||
| ENS 44774 | 14 January 2009 05:00:00 | 10 CFR 30.50(b)(2) 10 CFR 21.21 | Part 21 Report Due Potential Issue of Afterloader Source Sticking | The active source may have movement difficulties and become stuck during source extension or retraction. The problem may occur with the source outside of the HDR unit's tungsten shield. This type of event was first seen in December 2008. This event has occurred three times: "a) Southwest Regional Cancer Center, Austin TX - December 2, 2008 (see EN #44697) "b) Hershey Medical Center, Hershey PA - December 11, 2008 c) Stanford University Medical Center, Stanford, CA - December 30, 2008 In each case the problem occurred during a routine source exchange and patients were not involved. The emergency retract handle was used in each occurrence to retract the source and park it safely in the HDR unit's tungsten shield. The relationship between the source exchange and the problem is unknown. The affected sites in the United States are as follows: St. Joseph's - Mercy Hospital of Macomb - Clinton Twp., MI Cancer Healthcare Associates Cedars Med Ctr - Miami, FL Providence Hospital - Anchorage, AK Coborn Cancer Center - St. Cloud, MN Stanford University Medical Center - Palo Alto, CA Barnes Jewish #2 - Washington University - St. Louis, MO Mayo Clinic - Rochester, MN DeKalb Medical Center - Decatur, GA Cy-Fair Cancer Center - Houston, TX Billings Clinic - Billings, MT Palm Beach Cancer Institute - West Palm Beach, FL St. Lukes - Bethlehem, PA University of Nebraska Medical Center - Omaha, NE Geisinger Health System - Wilkes-Barre, PA Southwest Regional Cancer Center - Austin, TX Hershey Medical Center - Hershey, PA Carolinas Medical Center - Charlotte, NC Cheyenne Regional Medical Center - Cheyenne, WY Mary Washington Hospital - Fredericksburg, VA Treasure Coast Radiation Oncology - Stuart, FL Mayhill Denton Cancer Center - Denton, TX Hamilton Medical Center - Dalton, GA Providence Hospital - Everett, WA Good Samaritan Hospital - Downers Grove, IL Seattle Cancer Care Alliance - Seattle, WA
After conferring with Region 1 (Gabriel) and NRC HQ (Flannery) the licensee is also reporting this under 10 CFR 30.50(b)(2). Notified R1DO (Burritt) and FSME (Flannery). |