The following information was received via E-mail:
On the evening of April 24, 2014 Elekta, (Georgia license - GA 1153-2) working under a Nebraska reciprocity general license, was installing the initial source (9.98 curies of lr-192) into the new Flexitron unit at Saint Francis Medical Center (Nebraska Radioactive Material License # 08-09-01) in Grand Island, Nebraska. During the upload procedure, the source did not completely retract into the safe and became hung-up on the in-drive. The device gave an error stating the source was detached from the cable. Following the manufacturer's recommended emergency procedures, the engineer entered the room to investigate the issue and determined the source cable needed to be cut to remove it from the stuck source drive. The Field Service Engineer (FSE) then quickly cut the exposed source cable and, using pliers, manually inserted the source into the transport container. However, due to the fact that the source cable was short, he could not get it completely into the center of the shielded transport container. The exposure rate at one meter from the transport container was 200 mR/hour. The facility physicist and FSE insured the door to the treatment room was sealed and marked so no one could enter overnight.
The following morning, April 25, 2014, work began to construct temporary shielding made of lead bricks on a trolley in order to transport the container to the facility hot lab. Additionally, arrangements were made with Elekta's source manufacturer to acquire a type A container of the proper size to house and ship the source transport container to their facility, thus removing it from St. Francis premises.
Elekta's Radiation Safety Officer failed to notify the State of Nebraska Radioactive Material's Program in a timely manner. The incident occurred after business hours and Friday April 25, 2014 was a State holiday (Arbor Day). No call was made to the emergency call number for the State and the information was only obtained by the Nebraska Program Manager by a series of e-mails and a voicemail after 0800 CDT on Monday, April 28, 2014.
Item Number: NE14003
- * * UPDATE FROM TRUDY HILL TO CHARLES TEAL AT 1659 EDT ON 6/16/14 * * *
The following information was received via email:
On April 29, 2014, a special Type A container from Alpha Omega Services (AOS) arrived on site and the source was packaged in it for shipment. On May 1, 2014, source was shipped to AOS. On May 7, 2014, the source was received at AOS facility for safe decay storage before shipping back to Mallinckrodt.
On May 21 & 22, 2014, the HDR unit involved in the incident was shipped back to Nucleotron B. V. in the Netherlands for investigations. No results as of June 16, 2014.
Notified R4DO (Hay), R1DO (Welling) and FSME Event Resource via email.
- * * UPDATE FROM TRUDY HILL (VIA EMAIL) TO HOWIE CROUCH AT 1123 EDT ON 09/09/14 * * *
The following information was obtained via email:
As of July 25, 2014 there is still no determination as to the cause of the source hang-up. The HDR unit is still being analyzed at the factory in the Netherlands.
As of August 27, 2014, Elekta's R & D Department has not uncovered the root cause of the incident. Extensive analysis of the drive and the log files have not been able to reproduce the specific error. R & D are in the final stages of the root cause investigation and should be completed soon.
On September 8, 2014, Elekta submitted their close out report on the incident. After exhaustive & extensive analysis of the drive and the log files, the R & D Department has not been able to reproduce the specific error and could not uncover the root cause of the incident.
Nebraska considers this report as closed.
Notified R1DO (Jackson), R4DO (Azua) and
FSME Events Resource via email.