Information Notice No. 87-18: Unauthorized Service on Teletherapy Units by Nonlicensed Maintenance Personnel

                                                         SSINS No.: 6835 
                                                           IN 87-18       
                                UNITED STATES
                        NUCLEAR REGULATORY COMMISSION
                    OFFICE OF INSPECTION AND ENFORCEMENT
                           WASHINGTON, D.C. 20555

                                April 8, 1987

Information Notice No. 87-18:   UNAUTHORIZED SERVICE ON TELETHERAPY 
                                   UNITS BY NONLICENSED MAINTENANCE 
                                   PERSONNEL 

Addressees: 

All NRC licensees authorized to use radioactive material in teletherapy 
units. 

Purpose: 

This notice is provided to alert recipients that they may be in 
noncompliance with their NRC teletherapy licenses should "in-house" or 
contract maintenance personnel be used to service or repair the licensees' 
teletherapy equipment. It is expected that recipients will review the 
information for applicability to their facilities and take actions to 
preclude a similar problem from occurring at their facilities. However 
suggestions contained in this information notice do not constitute NRC 
requirements; therefore, no specific actions or written response is 
required. 

Description of Circumstances: 

During recent inspections of teletherapy licensees, NRC staff discovered 
that some licensees are using unlicensed, "in-house" engineers, 
electricians, or maintenance personnel to perform maintenance or repair on 
teletherapy equipment. On one occasion, an NRC licensee allowed an 
unlicensed, "in-house" staff member to repair a valve in the pneumatic 
systems used to return the cobalt-60 source drawer to the shielded position 
in a teletherapy unit manufactured by Atomic Energy of Canada, Limited 
(AECL). 

Other examples where maintenance or repair operations were performed by 
unlicensed, "in-house" staff follow: 

a.   An NRC licensee performed service work on the cord reel assembly for 
     the field defining light of an AECL Theratron 80 unit. NRC inspection 
     findings concluded that this repair was the most likely cause for the 
     unit's source drawer sticking in the exposed position, resulting in 
     unnecessary exposure to two therapy technologists and the patient. 

b.   Two NRC licensees were found to be in noncompliance with their 
     licenses when it was determined that the licensees had disassembled 
     and repaired pneumatic lines and valves. 


8704080015
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                                                            IN 87-18     
                                                            April 8, 1987 
                                                            Page 2 of 3  

c.   Reports have been received from licensees and teletherapy equipment 
     manufacturers describing instances where NRC licensees' maintenance 
     staff have replaced or repaired interlocks to teletherapy room doors. 
     These devices are considered a part of the teletherapy unit's safety 
     mechanism. 

d.   Reports have been received concerning NRC licensees performing 
     "in-house" maintenance and repair upon teletherapy control panels, 
     e.g. replacement of radiation beam guide lights which indicate source 
     exposure, switches which activate or terminate radiation exposure, and 
     therapy treatment timers. These devices are considered a part of 
     teletherapy unit's safety mechanisms. 

e.   Reports have been received from teletherapy equipment manufacturers 
     and teletherapy service companies of cases where NRC licensees' staff 
     have removed safety-related components for "in-house" repair or 
     replacement, e.g. , treatment timers, relays, and circuit boards. 

Discussion: 

The NRC considers such repairs as an operation defined in the standard 
license condition printed below. Consequently, the use of an unlicensed 
individual to perform certain operations is in noncompliance with this 
condition. 

The standard license condition for all teletherapy use specifically states: 

     The following shall be performed only by persons specifically licensed 
     by the Commission or an Agreement State to perform such services: 

     a.   Installation, relocation, or removal of teletherapy units 
          containing sources. 

     b.   Source exchange. 

     c.   Any maintenance or repair operation on a teletherapy unit 
          involving work on the source drawer, the shutter, or other 
          mechanism that could expose the source, reduce the shielding 
          around the source, or compromise the safety of the unit and 
          result in increased radiation levels. 

Not only is the maintenance described above in the license condition 
required to be done by persons specifically licensed to perform such 
services, but servicing and maintenance at 5-year intervals also is required 
to be performed by persons with a specific license pursuant to 10 CFR 35.26.

The NRC staff has determined that service by individuals who are unqualified 
and lack specific knowledge of the associated radiation hazards of the 
device poses a significant risk to the health and safety of individuals 
performing the actual repairs, patients receiving treatment, teletherapy 
staff technologists, and the general public in unrestricted areas adjoining 
the teletherapy facility.
.

                                                            IN 87-18
                                                            April 8, 1987 
                                                            Page 3 of 3  

Licensees authorized to possess and use teletherapy equipment containing 
cobalt-60 or cesium-137 should be aware of their responsibility to ensure 
compliance with 10 CFR 35.26 and the standard license condition. Licensees 
who desire to have these operations performed by qualified "in-house" staff 
members who are not authorized by the NRC or an Agreement State must request 
an amendment to their license. 

No written response is required by this information notice. If you have 
questions regarding this matter please contact the Regional Administrator of 
the appropriate NRC regional office or this office. 




                         James G. Partlow, Director
                         Division of Inspection Programs
                         Office of Inspection and Enforcement

Technical Contacts: J. Metzger, IE
                    (301) 492-4947 

                    H. Karagiannis, IE
                    (301) 492-9655

Attachment:
List of Recently Issued IE Information Notices
.