PNO-I-86-001, on 860109,technician Entered High Radiation Area During Treatment of Patient Undergoing Co-60 Teletherapy.Door Interlock on Treatment Room Inoperative. Exposure Estimated at No Greater than 100 Mrems
| ML20137A439 | |
| Person / Time | |
|---|---|
| Site: | 03009588 |
| Issue date: | 01/10/1986 |
| From: | Glenn J, Joyner J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| References | |
| PNO-I-86-001, PNO-I-86-1, NUDOCS 8601140381 | |
| Download: ML20137A439 (2) | |
s DCS: 03009588/860901 Date: January 10, 1986 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-I-86-01 This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is as initially received without verification or evaluation, and is basically .I that is known by the Region I staff on this date.
Facility: Washington Hospitai Center Licensee Emergency Classification:
Washington, D.C. 20010 Notification of Unusual Event (L/N: 08-03604-04) Alert Site Area Emergency General Emergency X Not Applicable
Subject:
ENTRY INTO HIGH RADIATION AREA WITH TELETHERAPY INTERLOCKS IN0PERABLE The licensee's Radiation Safety Officer (RS0) reported by telephone at about 3:00 p.m. January 9, that a technician had entered a high radiation area earlier in the day during the treatment of a patient undergoing cobalt-60 teletherapy. The RSO had been notified at 7:50 a.m. on January 9 that a door interlock on the treatment room was inoperative. The interlock is required to assure that the teletherapy source returns to a safe, shielded position if the door is opened during treatment. The RSO confirmed that the interlock was not functioning, but did not instruct the technicians to suspend treatment until the interlock was repaired, only to exercise caution when opening the door to enter the treatment room.
While the RSO was getting wiring diagrams to aid in repairing the interlock, a technician initiated treatment of a patient. The technician watched the patient through a remote reviewing system, and upon hearing a click and believing the treatment was completed, entered the room and started to make adjustments to the teletherapy unit. A second technician noted a red light on the console, indicating the source was exposed, and hit the emergency switch, returning the source to the shielded position. Treatments were then suspended until the interlocks were repaired and declared operational about two hours later.
At this time, it is believed that no part of the technician's body was exposed to the direct beam of the teletherapy unit. Therefore, the technician's exposure has been initially estimated to be no greater than 100 mrem, which is not considered to be significant. The technician's film badge has been sent for emergency processing. A Region I health physicist has been dispatched tu the site to review the circumstances of the incident.
The Government of the District of Columbia has been informed.
CONTACT: J. Glenn J. Joyner i 488-1250 488-1251 l
l 8601140381 860110 j PDR I&E D'I l PNO-I-86-OO1 PDR
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PN0 86-01/860901 JL DISTRIBUTION:
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(Reactor Licensees)
Region I Forn 83 (Rev. January 1983)
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