Description of Event or Problem · 1
ACCORDING TO THE RPTR, AN INCIDENT OCCURRED IN 05-1995 DUE TO A FAILURE OF A COMPONENT KNOWN AS A CRYDOM. THIS FIRST INCIDENT WAS NOT REPORTED SINCE THE MFR DETERMINED THE INCIDENT TO BE RELATED TO OPERATOR ERROR. THE MFR WAS TO HAVE CONTACTED THE FACILITY WITH STRATEGIES TO PREVENT FUTURE PROBLEMS, BUT NO SUCH CONTACT EVER TOOK PLACE. THE INCIDENT WHICH OCCURRED IN MARCH WAS ALSO DUE TO A CRYDOM FAILURE WHICH RESULTED IN TRANSISTOR CONTROL RELAYS SHORTING OUT. ACCORDING TO THE RPTR, HIS STAFF WAS IN THE PROCESS OF COMPLETING A PT SIMULATION WHICH INVOLVES BRINGING THE GANTRY BACK INTO NORMAL CONFIGURATION. A TECH "HEARD A CRASH" AND NOTED THE IMAGE INTENSIFIER HAD FALLEN TO THE FLOOR. AFTER INVESTIGATING THE INCIDENT, THE RPTR WAS ABLE TO DETERMINE THE PROBLEM. THE DRIVE MOTOR FOR THE IMAGE INTENSIFIER HAD DRIVEN BEYOND THE PROGRAMMED CONTROL LIMIT. THE GANTRY WENT BEYOND ITS NORMAL ZERO DEGREE CONFIGURATION TO FOUR DEGREES. THE IMAGE INTENSIFIER BROKE FROM ITS WELDED BRACKET WHEN THE SUPPORT ARM FRACTURED INTO 2 PIECES. THE IMAGE INTENSIFIER FELL TO THE FLOOR LANDING IN A VERTICAL POSITION. THE CAMERA WAS DESTROYED AND SMOKING. AN IMAGE INTENSIFIER HAS BEEN PLACED BACK ONTO THE MACHINE WITH A NEW BRACKET. THE MACHINE HAS NOT YET BEEN TESTED. ALTHOUGH NO PT OR STAFF INJURIES RESULTED FROM THIS INCIDENT, THE RPTR FEELS THIS INCIDENT REPRESENTS A MAJOR SAFETY HAZARD. THE RPTR FEELS THE SVC PROVIDED TO THE FACILITY HAS BEEN "PATHETIC" AND PERHAPS THE POOR SVC MAY HAVE CONTRIBUTED TO THE FAILURE.