Headquarters Daily report APRIL 07, 1994 *************************************************************************** REPORT NEGATIVE NO INPUT ATTACHED INPUT RECEIVED RECEIVED HEADQUARTERS X REGION I X REGION II X REGION III X REGION IV X *************************************************************************** PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION II APRIL 7, 1994 Licensee/Facility: Notification: Tennessee Valley Authority MR Number: 2-94-0026 Watts Bar 1 Date: 04/07/94 Spring City,Tennessee Dockets: 50-390 PWR/W-4-LP Subject: WATTS BAR UNIT 1 HOT FUNCTIONAL TESTING Reportable Event Number: N/A Discussion: Watts Bar Unit 1 continued Hot Functional Testing and reached the 250 degree plateau on April 6. The licensee expects to be at this plateau for two or more days for testing and to make thermal expansion measurements. Regional Action: Region II is maintaining continuous inspection coverage. Contact: Johns P. Jaudon (404)331-5179 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION III APRIL 7, 1994 Licensee/Facility: Notification: Radiation Oncologists, P. C. MR Number: 3-94-0071 Radiation Oncologists, P. C. Date: 04/05/94 Rochester Hills,Michigan TELECON FROM MI DEPT PUBLIC HEALTH Subject: APPARENT OVEREXPOSURE Reportable Event Number: N/A Discussion: The Michigan Department of Public Health (MDPH) reported an apparent overexposure to radiation therapy technologists at the Registrant's facility. The incident occurred on the morning of April 4, 1994 and involved a 4 MeV linear accelerator, manufactured by ATC, which is under the State's jurisdiction. The linear accelerator apparently malfunctioned causing radiation to be emitted for about 10 seconds after each treatment cycle. Two technologists entered the accelerator room after each treatment during the course of patient therapies and are estimated to have received a maximum of 161 rad (161 centiGray) exposure to a portion of the body. The radiation beam was collimated to a 7 by 7 centimeter field. Patient doses do not appear to have been significantly increased as a result of the equipment malfunction. One of the technologists wore a film badge which identified a 20 millirem exposure, but was evidently worn outside of the collimated exposure area. The other technologist was not wearing a film badge or other dosimetry. Warning lights and interlocks are tied to the accelerator system, in accordance with State requirements, and as such are not designed to be activated by increased radiation levels in the room. NRC regulations require radiation-activated warning devices and interlocks in teletherapy rooms. MDPH notified the Food and Drug Administration (FDA) of the incident and together with the FDA, began an investigation at the Registrant's facility on April 5, 1994. The cause of the malfunction and generic implications are being investigated by MDPH and the FDA. The Registrant has been instructed, by MDPH, to obtain the services of an independent third party consultant to perform a medical assessment and reenactment of the incident. MDPH notified the Region III office of the incident on April 5, 1994 and requested names of medical consultants on contract to the NRC for medical assessments. The list of NRC-contracted consultants was provided to the State. Regional Action: Region III is monitoring the situation for informational purposes only. NMSS and OSP have been advised of the incident. Contact: J. LYNCH (708)829-9818 R. CANIANO (708)829-9804