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| Entered date | Event description | |
|---|---|---|
| ENS 41579 | 8 April 2005 17:18:00 | Lankenau Hospital reported an incident involving a Nucletron V2 microselectron High Dose Rate Afterloading device. The Hospital reports that a source stuck in a GYN transfer tube during quality operational checks. The source had to be manually retracted with a hand crank back into a safe position. Inspection of the GYN tube revealed a restriction (described as an edge) that developed on the end that connects to the treatment unit. The Hospital report states that the tube had been in use for two years and may have developed the restriction from normal wear and tear. The tube was replaced and the defective tube transferred to Nucletron. The Hospital report notes that normal wire transfer checks (without the source present) did not identify the problem - but probably should have. The Hospital report also stated that the restriction should not have prevent the source from being automatically retracted to its safe location once the emergency stop was actuated. The cause of the GYN tube restriction is unknown. |