Event Notification Report for March 14, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/13/2024 - 03/14/2024
EVENT NUMBERS
57029
57029
Agreement State
Event Number: 57029
Rep Org: MA Radiation Control Program
Licensee: UMass Chan Medical School
Region: 1
City: Worcester State: MA
County:
License #: 60-0096
Agreement: Y
Docket:
NRC Notified By: Bob Locke
HQ OPS Officer: Adam Koziol
Licensee: UMass Chan Medical School
Region: 1
City: Worcester State: MA
County:
License #: 60-0096
Agreement: Y
Docket:
NRC Notified By: Bob Locke
HQ OPS Officer: Adam Koziol
Notification Date: 03/15/2024
Notification Time: 12:00 [ET]
Event Date: 03/14/2024
Event Time: 12:25 [EDT]
Last Update Date: 03/15/2024
Notification Time: 12:00 [ET]
Event Date: 03/14/2024
Event Time: 12:25 [EDT]
Last Update Date: 03/15/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Jackson, Don (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Jackson, Don (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK SOURCE
The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:
"On 3/14/2024 at 1225 EDT, a MDS Nordion, Inc. GammaMed Plus iX high dose rate (HDR) remote afterloader device malfunctioned, leaving the source in an unshielded position. Since the quality assurance/quality control (QA/QC) checks are performed in a shielded room, no individuals received any excess dose due to this device failure.
"On the same day at 1630 EDT, individuals from a device manufacturer, Varian Medical Systems, Inc. (NRC License # 45-30957-01) came to the site and returned the device to a shielded position. One field agent received a dose of 0.025 mSv [2.5 mrem] during this operation.
"On 3/15/2024, Varian personnel performed work to repair the device. This repair work is ongoing at the time of this report.
"The Agency will follow up with UMass Healthcare Radiation Safety Officer (RSO) to determine event cause and corrective actions.
"The Agency considers this event open. The Agency will follow up with a special inspection of the licensee."
Device Information:
MDS Nordion, Inc. GammaMed Plus iX HDR remote afterloader (sealed source and device registry number: CA-1080-D-103-S)
Source Information:
MDS Nordion Inc. model GM 232, Ir-192, 4.4 Ci (sealed source and device registry number: CA-1080-S-104-S)
NMED Number: TBD
The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:
"On 3/14/2024 at 1225 EDT, a MDS Nordion, Inc. GammaMed Plus iX high dose rate (HDR) remote afterloader device malfunctioned, leaving the source in an unshielded position. Since the quality assurance/quality control (QA/QC) checks are performed in a shielded room, no individuals received any excess dose due to this device failure.
"On the same day at 1630 EDT, individuals from a device manufacturer, Varian Medical Systems, Inc. (NRC License # 45-30957-01) came to the site and returned the device to a shielded position. One field agent received a dose of 0.025 mSv [2.5 mrem] during this operation.
"On 3/15/2024, Varian personnel performed work to repair the device. This repair work is ongoing at the time of this report.
"The Agency will follow up with UMass Healthcare Radiation Safety Officer (RSO) to determine event cause and corrective actions.
"The Agency considers this event open. The Agency will follow up with a special inspection of the licensee."
Device Information:
MDS Nordion, Inc. GammaMed Plus iX HDR remote afterloader (sealed source and device registry number: CA-1080-D-103-S)
Source Information:
MDS Nordion Inc. model GM 232, Ir-192, 4.4 Ci (sealed source and device registry number: CA-1080-S-104-S)
NMED Number: TBD