ML20248L146
| ML20248L146 | |
| Person / Time | |
|---|---|
| Issue date: | 02/17/1978 |
| From: | Higginbotham L, Metzger J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| References | |
| PNO-78-033, PNO-78-33, NUDOCS 9806100455 | |
| Download: ML20248L146 (2) | |
Text
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PRELIMINARY NOTIFICATION February 17, 1978 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-78-33
_This preliminary notification constitutes EARLY notice of an event of POSSIBLE safety or public interest significance.
The information presented is as initially received without verification or evaluation and is basically all that is known by IE staff on this dLte.
Facility:
University of Pittsburgh School of Medicine (Magee-Womens Hospital)
Pittsburgh, Pennsylvania License No. 37-00134-07
Subject:
TELETHERAPY MALFUNCTION i
The licensee reported that its cobalt-60 teletherapy unit malfunctioned exposing the source during rotation of the unit on February 16 and 17, 1978.
On each occasion the unit's position was being adjusted immediately W
prior to beginning treatment and a patient was on the treatment table.
In each instance, the patient exposure'was estimated to be 10 rads above
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employees.
,1 that exposure which was intended. There were no execessive exposures to 1
On February 16, 1978, the teletherapy unit was being rotated to set up for j
the next patient exposure.
During the rotation the source became exposed r
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and was mechanically returned to its shielded position by the therapy
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technician.
The unit was taken out of operation and the local service O
representative was promptly summoned.
The representative identified and 2.
repaired a short circuit.
On February 17, 1978, a similar short circuit occurred exposing the source while the unit was being rotated during a set-up for another patient.
The licensee has taken the unit out of service until the fault is identified, corrected, and corrective actions thoroughly tested.
The licensee reported this incident because it is expected that the teletherapy unit will be out of operation for more than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.
A patient is typically given 200 rads in a treatment session. The addi-tional 10 rad dose is not expected to have any significant clinical effect.
Region 5 is following the licensee's actions and will conduct an inspection of the facility during the week of February 20, 1978, to insure proper correc-tive action.
Media interest is expected because of the nature of the occurrence and recent NRC action on teletherapy equipment.
The Commonwealth of Pennsyl-vania has been informed.
A press release is not planned by the licensee nor NRC.
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9806100455 780217
ONTINUED PDR I&E PNO-78-033 PDR
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Pagep PNO-78-33 Continued February 17, 1978 NRC Region I, (Philadelphia) received notification of this occurrence by telephone from the licensee's Radiation Safety Office at 11:45 a.m.,
February 17, 1978.
Contact:
JRMetzger, IE x28188 LBHigginbotham, IE X28098 Distribution:
Transmitted H St 9.'/.5' Chairman Hendrie Commissioner Bradford Commissioner Kennedy S. J. Chilk, SECY C. C. Kammerer, CA Commissioner Gilinsky (For Distribution)
Transmitted:
MNBB ff/3 P Bldg 42 /1 E. Volgenau Region 1, IE
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L. V. Gossick, ED0 E. G. Case, NRR 42!.2 2.
S. H. Hanauer, EDO J. J. Fouchard, PA SS Bldg W I C (MAIL) l R. Hartfield, MIPC C. V. Smith, NMSS T. J. McTiernan, 01A l
R. G. Ryan, OSP R. Minogue, SD H. K. Shapar, ELD PRELIMINARY NOTIFICATION
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