PNO-III-86-147, during Routine Insp,Inspectors Determined That Univ Personnel Instead of Licensed Technicians Repaired & Maintained Components of Co-60 Teletherapy Units.On 860412,therapeutic Timer Stopped During Treatment
| ML20211Q243 | |
| Person / Time | |
|---|---|
| Site: | 03010094, 03015101 |
| Issue date: | 12/16/1986 |
| From: | Mullauer J, Sreniawski D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| References | |
| CAL, PNO-III-86-147, NUDOCS 8612190225 | |
| Download: ML20211Q243 (1) | |
P PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-III-86-147 Date D cember 16, 1986 De 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 all that is known by the Region III
- staff on this date.
Facility: Washington University Licensee Emergency Classification:
St. Louis, Missouri Notification of an Unusual Event Alert License No. 24-0063-08 Site Area Emergency 3d /MN License No. 24-0063-10 General Emergency r
X Not Applicable 86 /NO /
Subjrct:
UNAUTHORIZED REPAIR OF TELETHERAPY UNITS During a routine safety inspection, Region III (Chicago) inspectors determined that university personnel have routinely maintained and repaired certain components of the university's two c:balt-60 teletherapy units.
Regulations require these units to be serviced only by technicians lic:nsed by the NRC. This situation has apparently existed for many years.
On April 12, 1986, during a therapeutic treatment, the timer stopped on one of the teletherapy units and the cobalt-60 source failed to retract into its shielded position. The licensee followed its emergency procedure, removing the patient and manually retracting the source.
Th2 licensee's maintenance department repaired a broken air pressure valve, which had disabled tha retracting mechanism.
Because of the malfunction, the patient received only 1930 rads during treatment, rather than th 2000-rad prescribed dose.
Film badges of all licensee personnel-involved in the incident were processed. Exposures were within regulatory limits.
R;gion III has issued a Confirmatory Action Letter in which the licensee has agreed to recalibrate the units, and bring in authorized personnel to perform a full five-year maintenance inspection. The licensee also has agreed to refrain from using unauthorized personnel in th future.
R gion III continues to review this matter.
Th2 State of Missouri will be notified.
,h This information is current 1 p.m. (C T)
December 16,1986.h Y
If CONTACT:
. MD 1 er;.Q.Q D. S eniawski iabe g
a \\
1 TS 388-5623 FTS 8-5611 i
DISTRIBUTION:
H. St.
ED0 NRR E/W Willste Mail: ADM:DMB Chairman Zech PA IE N'3S DOT:Trans only Com. Roberts ELD OIA RES Comm. Asselstine AE0D NRC Ops Ctr yf Comm. Bernthal Comm. Carr SP /,8 Regional Offices ACRS SECY INP0 NSAC CA RIII Resident Office PDR Licensee:
(Corp. Office - Reactor Lic. Only)
Region III e612190225 861216 Rev. November 1986
. N.I 86-147 PDR