Information Notice 1988-93, Teletherapy Events

Teletherapy Events

ML031150029
Person / Time
Site:	Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant
Issue date:	12/02/1988
From:	Cunningham R NRC/NMSS/IMNS
To:
References
IN-88-093, NUDOCS 8811290030
Download: ML031150029 (5)

UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS

WASHINGTON, D.C. 20555 December 2, 1988 NRC INFORMATION NOTICE NO. 88-93: TELETHERAPY EVENTS

Addressees

All NRC medical licensees.

Purpose

This notice is intended to alert recipients to the circumstances leading to

two recent teletherapy events and to emphasize the importance of the correct

use of computerized treatment-planning. It is expected that licensees will

review this information for applicability to their programs, distribute this

notice to those responsible for radiation safety, and consider actions, if

appropriate, to preclude a similar situation from occurring at their facilities.

However, suggestions contained in this notice do not constitute any new NRC

requirements, ana no written response is required.

Description of Circumstances

In March 1987, following a source exchange for a cobalt-6C teletherapy unit

at a hospital in an Agreement State, the higher activity of the new source was

not properly accounted for in the computerized treatment-planning system. In

particular, the computer program related to the use of beam trimmers was not

updated because the beam trimmers were not being used by the licensee at the

time of source exchange. At a later date, the licensee began using beam

trinmiers again and based its treatment planning calculations on the incorrect

old source output. Because the licensee failed to update the program with the

new source output, 33 patients received doses 75 percent in excess of the

prescribed doses.

In a second case, in a different Agreement State, teletherapy events occurred

at three different hospitals. Each of these hospitals used a different

treatment-planning computer system. A consulting physicist who was working

at all three of the hospitals made random errors when using the programs.

The errors made indicated a misunderstanding of the computer parameter

definitions and the limitations of the different treatment-planning systems.

8811290030 AtAd \ -8/

c a4 IN 88-93 December 2, 1988 Discussion:

All medical licensees are reminded of the importance of making accurate

therapy-dose calculations, including computer-assistea calculations. This

is particularly important on occasions when the operating characteristics

of the equipment might have been modified, such as-after servicing or a

source exchange. Licensees should consider methods to ensure that only

updated programs and data files are used in treatment planning. In addition, licensees should consider steps to ensure that individuals using treatment- planning computer systems are properly trained in the use and limitations of

those systems.

No written response is required by this information notice. If you have any

questions about this matter, please contact the appropriate NRC regional

office or this office.

Richard E. Cunningham, Director

Division of Industrial and

Medical Nuclear Safety

Officeaof Nuclear Material Safety _

and Safeguards

Technical Contacts: U. R. Metzger, NIMSS

(301) 492-3424 J. McGrath, Region I

(215) 377-5216 Attachment: List of Recently Issued NRC Information Notices

Attachment

IN 88-93 December 2, 1988 LIST OF RECENTLY ISSUED

NRC INFORMATION NOTICES

Information Date of

Notice No. Subject Issuance Issued to

88-92 Potential for Spent Fuel 11/22/88 All holders of OLs

Pool Draindown or CPs for nuclear

power reactors.

88-91 Improper Administration 11/22/88 All holders of OLs

and Control of or CPs for nuclear

Psychological Tests power reactors and

all fuel cycle facility

licensees who possess, use, import, export, or transport formula

quantities of strategic

special nuclear material.

88-90 Unauthorized Removal of 11/22/88 All NRC licensees

Industrial Nuclear Gauges authorized to possess, use, manufacture, or

distribute industrial

nuclear gauges.

88-89 Degradation of Kapton 11/21/88 All holders of OLs

Electrical Insulation or CPs for nuclear

power reactors.

88-88 Degradation of Westinghouse 11/16/88 All holders of OLs

ARD Relays or CPs for nuclear

power reactors.

88-87 Pump Wear and Foreign 11/16/88 All holders of OLs

Objects in Plant Piping or CPs for nuclear

Systems power reactors.86-106, Feedwater Line Break 11/10/88 All holders of OLs

Supp. 3 or CPs for nuclear

power reactors.

88-86 Operating with Multiple 10/21/88 All holders of OLs

Grounds in Direct Current or CPs for nuclear

Distribution Systems power reactors.

OL = Operating License

CP = Construction Permit

IN 88- November , 1988 Discussion:

All medical licensees are reminded of the importance of making accurate

therapy-dose calculations, including computer-assisted calculations. This is

particularly important on occasions when the operating characteristics of the

equipment might have been modified, such as after servicing or a source

exchange. Licensees should consider methods to ensure that only updated

programs and data files are used in treatment planning. In addition, licensees should consider steps to ensure that individuals using treatment- planning computer systems are properly trained in the use and limitations of

those systems.

No written response is required by this Information Notice. If you have any

questions about this matter, please contact the appropriate NRC regional

office or this office.

Richard E. Cunningham, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical Contacts: J. R. Metzger, NMSS

(301) 492-3424 J. McGrath, Region I

(215) 377-5216 Attachment: List of Recently Issued NRC Information Notices

XOGC - A") #& 4~~,/civ sale o larbte

0 ee previous concurrence OC,- #

Editor: E. Kraus 11/21/88 11/J/88 OFC :IMOB IMOB IMAB RI IMOB GPA/SLITP MD State IMN N

~~~~~~~~~~~~~---------- -- Sl------/--------------____ _

______4AM_

NAME:JMetzge>sr Mpf JAustin JMcGratR JV~key VMiller ----- G RCunningham

DATE:11/ /88 1Y/J./88 11/ /88 11/ /88 11/.ff/88 11/ /88 11/ /88 11/23/88 11/23/88 OFFICIAL RECORD COPY

IN 88- November , 1988 Discussion:

All medical licensees are reminded of the importance of making accurate

therapy-dose calculations, including computer-assisted calculations. This is

particularly important on occasions when the operating characteristics of the

equipment might have been modified, such as after servicing or a source

exchange. Licensees should consider methods to ensure that only updated

programs and data files are used in treatment planning. In addition, licensees should consider steps to ensure that individuals using treatment- planning computer programs are properly trained in the use and limitations of

those systems.

No written response is required by this Information Notice. If you have any

questions about this matter, pl ase contact the appropriate NRC regional

office or this office.

Richard E. Cunningham, Director

ivision of Industrial and

Medical Nuclear Safety

O ice of Nuclear Material Safety

a d Safeguards

Technical Contacts: J. R. Metzger, NMSS

(301) 492-3424 J. McGrath, Region I

(215) 377-5216 Attachment: List of Recently Issued NRC Informati n Notices

See previous concurrence

Editor: E. KraU-S\11/21/88 OFC....O M ... IMUB --- AI I A1 te IMNS IMNS

0_1t - - Th-------c--------------------------

---

NAME:J t ger/sr DCool J stin iAMcG~ath JHickey M _

-ler GSjoblom RCunningham

DATE:11/22/88 11/ /88 11/2Z/88 1110i/88 11/ /88 11/4i/88 11/.,/88 11/ /88 11/ /88 OFFICIAL RECORD COPY