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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 54204 | 7 August 2019 04:00:00 | 10 CFR 20.2201(a)(1)(i) 10 CFR 30.50(a) | Iridium-192 Source Lost During Shipment | A 0.78 Curie (today's activity) Ir-192 source was lost during shipment from the Mayo Clinic in Rochester, MN to Alpha-Omega Services in Vinton, LA. The last known location was Memphis, TN with the common carrier. Its original shipment date was February 8, 2019. The licensee contacted the common carrier upon suspicion of loss on June 4, 2019. On August 7, 2019, the source had not been located and was deemed lost. THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 52944 | 30 August 2017 04:00:00 | 10 CFR 20.2201(a)(1)(i) | Iridium-192 Source Lost During Shipment | A 3.792 Curie Ir-192 source was removed from a Varian High Dose Rate afterloader and prepared for shipment by common carrier. The packaged source was picked up from Glens Falls Hospital in Glens Falls, New York by a representative of the common carrier on August 21, 2017. The destination of the source was to Alpha-Omega Services in Vinton, Louisiana for disposal. The source arrived at the common carrier's local station in Manands, New York on August 22, 2017. When the licensee checked package tracking information on August 30, 2016, the licensee noted that the package indicated that it was still at the common carrier's local station. The licensee attempted to contact the common carrier on August 30, 2017 without success. The licensee successfully contacted the common carrier on August 31, 2017 and the common carrier initiated a 'station trace' at that time. At the present time the source has not been located. The common carrier is still searching.
The Ir-192 source was located by the common carrier at 1837 PDT on 9/1/17. The package was delivered to the recipient on 8/29/17. Notified R1DO (Dentel), NMSS Events Notification, and Canada. THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9) | ||
| 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 46758 | 23 March 2011 04:00:00 | 10 CFR 21.21, Notification of failure to comply or existence of a defect and its evaluation | Potential Defect Identified in a Varian Medical Systems High Dose Rate Afterloader | On March 23, 2011, a technician was installing a VariSource High Dose Rate (HDR) Afterloader - Model VariSource IX 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. (See NRC Event Notice 46695) Engineering evaluation by the vendor, Varian Medical Systems, Inc., has identified a very small amount of material in the wedge block which has a small bore that the source wire passes through. Otherwise, nothing remarkable was identified. This machine is a new unit with a very low number of source extensions. There is no history of similar events with new units of this type. The vendor has issued a Tech Tip for all new sites and is investigating a new design for the wedge block with a goal of implementing any new design by April 30, 2012. Additionally, all VariSource HDR customers have received a copy of Customer Technical Bulletin CTB-VS-640A that discusses the potential of source wire path constriction and source wire jamming. | ||
| 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). | ||
| ENS 43532 | 27 July 2007 18:15:00 | Agreement State | Agreement State Report - Failure of Source to Retract | The State provided the following information via email: ODH Bureau of Radiation Protection received a phone call from Varian Medical Systems at approximately 3:15 PM EDT regarding a situation which had occurred at a customer's location (St. Elizabeth Hospital in Youngstown, Ohio). The incident occurred at approximately 2:15 PM EDT. A Varian technician was performing maintenance on a Gamma Med Model 12i HDR unit, with the source extended into a shielded safe. During the maintenance action the technician disconnected a nylon tube that was part of the source wire travel path. This action caused the retract mechanism in the unit to energize, retracting the source wire from the safe, exposing approximately 8 inches of the source wire and the source end. The source is approximately 9.5 Curies of Iridium-192. Varian personnel believe that the disconnection of the nylon tube reduced the tension on the source wire, causing the park switch to no longer sense the presence of the wire, and energizing the retraction mechanism, which then pulled the source from the safe. The technician realized that something was not right when he heard the drive mechanism energize, and exited the treatment room immediately. Varian estimates the exposure to the technician as approximately 15 mrem, based on the activity of the source and time required to exit the room. The technician was not wearing his dosimetry at the time the incident occurred. Varian is sending an additional engineer to the customer location to assist with source recovery, with an estimated arrival time between 7:00 PM and 8:00 PM EDT. Varian has set-up a mock scenario at their office with the same model unit in the same configuration as what is present at the customer site. They have performed run throughs of source recovery, and have determined that the most effective method of retrieval will be to grasp the source wire with 18" forceps and then guide the source wire back into the shielded safe. They expect the evolution to take 5 - 8 seconds with an estimated whole body exposure of 25 mrem or less. Ohio report # 2007-046 | ||
| ENS 43647 | 15 July 2007 04:00:00 | 10 CFR 21.21 | Active Source Can Become Dislodged in Hdr Afterloader Device | The following information was received via fax: Manufacturer submitted this notification based on an event involving a High Dose Rate (HDR) Afterloader that occurred at City of Hope Hospital in Duarte, California on July 15, 2007 (See EN# 43493) Identification of the facility, the activity, or the basic component supplied for such facility or such activity within the United States which fails to comply or contains a defect- VariSource HDR Afterloader model 200 and VariSource HDR Afterloader model ID Identification of the firm constructing the facility or supplying the basic component which fails to comply or contains a defect: The VariSource HDR Afterloader is manufactured by: Varian-TEM Ltd., Gatwick Road, Crawley, West Sussex RH102RG, United Kingdom Nature of the defector failure to comply and the safety hazard which is created or could be created by such defect or failure to comply: The active source can become dislodged from the internal tungsten safe if the emergency source retract hand crank is used when the active source is safely parked in the internal shield. (1) This event can only occur if the operator turns the emergency hand crank while the source is safely parked. (2) The emergency source retract hand crank is to be used only when the active source is in the out or exposed position. It is not designed, nor intended to be operated when the source is safely parked. (3) The emergency hand crank is only connected to the active source wire. It is not connected to the dummy source and its operation has no effect on the dummy source. Customer Technical Bulletin, CTB-VS-366A, "Clarification on the use of the emergency retract hand wheel to prevent accidental exposure" was issued to all users of the VariSource HDR unit on April 27, 2004. This CTB will be reissued to all domestic customers. A warning label addressing the proper use of the emergency hand crank was attached to all VariSource HDR units in 2004. A new warning label is being developed that will restate the proper use of the hand crank. Also a formal revision was made to user training to emphasize that this event is possible if the user makes an error by operating the emergency hand crank when the active source wire is safely parked in the tungsten shield. There are 186 VariSource HDR units in the United States and a list was provided to the NRC. | ||
| ENS 42618 | 4 April 2006 12:00:00 | Agreement State | Agreement State - Unplanned Exposure During Training | The State provided the following information via email: The Kentucky Radiation Health Branch was notified on April 4, 2006, by (the licensee), Radiation Safety Officer for Varian Medical Systems, 700 Harris Street, Suite 109, Charlottesville, VA, NRC license no. 45-30957-01, of an incident involving an HDR unit at the University of Kentucky Medical Center. A 10.5 Ci (Curie) Ir-192 brachytherapy HDR source assembly (SS&D registry no. CA-1080-S-102-S) on a VariSource Brachytherapy HDR Remote Afterloader (SS&D Registry no. CA-0661-D-103-S) had been extended beyond the shielded source housing by manually turning the over ride handle on the emergency retraction system. The incident occurred during a training exercise simulating an emergency HDR source retraction involving a medical physicist and four (4) medical students. The unit was in the 'Idle' mode which disabled the internal GM and emergency retract system on the HDR unit. The source was recovered by the RSO and two Varian service representatives on April 7, 2006. The state is awaiting official notification of the actual doses received but reported that the highest dose was around 20-30 milliRem. |