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Session: FLASH RT - Instrumentation and Dosimetry [Return to Session]

FMEA of FLASH On a Clinical LINAC Shows Setup and Beam Gating as Largest Risks

M Rahman1*, R Zhang1,2,3, D Gladstone1,2,3, B Williams1,2,3, E Chen4, L Thompson3, P Bruza1, B Pogue1,3,5,6, (1) Thayer School of Engineering, Dartmouth College, Hanover, NH, (2) Department of Medicine, Radiation Oncology, Geisel School of Medicine, Dartmouth College Hanover NH, (3) Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, (4) Cheshire Medical Center, Keene NH Department of Surgery, (5) Geisel School of Medicine, Dartmouth College, Hanover NH, (6) University of Wisconsin-Madison, Madison, WI


SU-E-BRC-3 (Sunday, 7/10/2022) 1:00 PM - 2:00 PM [Eastern Time (GMT-4)]

Ballroom C

Purpose: Use of clinical linear accelerators in ultra-high dose rate (UHDR) mode can provide a conduit for wider access to UHDR FLASH effects, sparing normal tissue, but care needs to be taken in the use of such systems to ensure errors are avoided. A Failure Modes and Effects Analysis (FMEA) was conducted with a team involved in converting a LINAC between clinical use and UHDR experimental mode for more than one year.

Methods: The risk analysis followed the proposed methods of AAPM (The American Association of Physicists in Medicine) Task Group 100 report. A team of 9 professionals with extensive experience outlined the process map and workflow for analysis, and developed fault trees for potential errors, as well as failure modes that would result. The team scored the categories of severity magnitude (S), occurrence likelihood (O), and detectability potential (D) on a scale of 1 to 10, so that a risk priority number (RPN=S*O*D) could be assessed for each potential failure.

Results: A total of 46 potential failure modes were identified, including 5 with RPN>100, all during converting and experimental use in UHDR mode and none during conversion to clinical mode. These failure modes involved 1) patient set up, 2) gating mechanisms in delivery, and 3) detector in the beam stop mechanism. Identified methods to mitigate errors included 1) use of a checklist post conversion, 2) use of robust radiation detectors, 3) automation of QA and beam consistency checks, and 4) implementation of surface guidance and monitoring during beam delivery.

Conclusion: The FMEA process was considered essential in this setting of a new use of a LINAC, and the expert team developed a higher level of confidence in the ability to safely move UHDR LINAC use towards expanded research access.

Funding Support, Disclosures, and Conflict of Interest: This work was supported by Norris Cotton Cancer Center seed funding (core grant P30CA023108 and shared irradiation service), Thayer School of Engineering seed funding, NIH grants (R01EB023909, R01EB024498, R42CA224646-02), and Department of Medicine (SEAM) Awards Program from the Dartmouth Hitchcock Medical Center and Geisel School of Medicine.


Electron Therapy, Risk


TH- External Beam- Electrons: General (most aspects)

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