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All sourcesNASA NTRSDOE OSTI
NASA NTRS1997

Aviation Safety Reporting System: Process and Procedures

The Aviation Safety Reporting System (ASRS) was established in 1976 under an agreement between the Federal Aviation Administration (FAA) and the National Aeronautics and Space Administration (NASA). This cooperative safety program invites pilots, air traffic controllers, flight attendants, maintenance personnel, and others to voluntarily report to NASA any aviation incident or safety hazard. The FAA provides most of the program funding. NASA administers the program, sets its policies in consultation with the FAA and aviation community, and receives the reports submitted to the program. The FAA offers those who use the ASRS program two important reporting guarantees: confidentiality and limited immunity. Reports sent to ASRS are held in strict confidence. More than 350,000 reports have been submitted since the program's beginning without a single reporter's identity being revealed. ASRS removes all personal names and other potentially identifying information before entering reports into its database. This system is a very successful, proof-of-concept for gathering safety data in order to provide timely information about safety issues. The ASRS information is crucial to aviation safety efforts both nationally and internationally. It can be utilized as the first step in safety by providing the direction and content to informed policies, procedures, and research, especially human factors. The ASRS process and procedures will be presented as one model of safety reporting feedback systems.

Connell, Linda J.↗
NASA NTRS2006

TOPEX Radar Altimeter Engineering Assessment Report Final Update-Side B Turn-On to End-of-Mission on October 9, 2005

This is the thirteenth and final report in a series of TOPEX Radar Altimeter Engineering Assessment Reports. The initial TOPEX Radar Altimeter Engineering Assessment Report, in February 1994, presented performance results for the NASA Radar Altimeter on the TOPEX/POSEIDON spacecraft, from its launch in August 1992 to February 1994. Since the time of that initial report and prior to this report, there have been eleven interim supplemental Engineering Assessment Reports, issued in March 1995, May 1996, March 1997, June 1998, August 1999, September 2000, June 2001, March 2002, May 2003, April 2004 and September 2005. The sixth supplement in September 2000 was the first assessment report that addressed Side B performance, and presented the altimeter performance from Side B turn-on until the end of calendar year 1999. This report extends the performance assessment of Side B to the final collection of data on October 9, 2005, and includes the performance assessment of Jason-1, the TOPEX follow-on mission, launched on December 7, 2001. This report provides some comparisons of Side A and Side B performance.

Lockwood, Dennis W.↗
NASA NTRS2011

Space Shuttle Guidance, Navigation, and Rendezvous Knowledge Capture Reports

This document is a catalog and readers guide to lessons learned, experience, and technical history reports, as well as compilation volumes prepared by United Space Alliance personnel for the NASA/Johnson Space Center (JSC) Flight Dynamics Division.1 It is intended to make it easier for future generations of engineers to locate knowledge capture documentation from the Shuttle Program. The first chapter covers observations on documentation quality and research challenges encountered during the Space Shuttle and Orion programs. The second chapter covers the knowledge capture approach used to create many of the reports covered in this document. These chapters are intended to provide future flight programs with insight that could be used to formulate knowledge capture and management strategies. The following chapters contain descriptions of each knowledge capture report. The majority of the reports concern the Space Shuttle. Three are included that were written in support of the Orion Program. Most of the reports were written from the years 2001 to 2011. Lessons learned reports concern primarily the shuttle Global Positioning System (GPS) upgrade and the knowledge capture process. Experience reports on navigation and rendezvous provide examples of how challenges were overcome and how best practices were identified and applied. Some reports are of a more technical history nature covering navigation and rendezvous. They provide an overview of mission activities and the evolution of operations concepts and trajectory design. The lessons learned, experience, and history reports would be considered secondary sources by historians and archivists.

John L Goodman↗
NASA NTRS2012

2011 NASA Range Safety Annual Report

Welcome to the 2011 edition of the NASA Range Safety Annual Report. Funded by NASA Headquarters, this report provides a NASA Range Safety overview for current and potential range users. As is typical with odd year editions, this is an abbreviated Range Safety Annual Report providing updates and links to full articles from the previous year's report. It also provides more complete articles covering new subject areas, summaries of various NASA Range Safety Program activities conducted during the past year, and information on several projects that may have a profound impact on the way business will be done in the future. Specific topics discussed and updated in the 2011 NASA Range Safety Annual Report include a program overview and 2011 highlights; Range Safety Training; Range Safety Policy revision; Independent Assessments; Support to Program Operations at all ranges conducting NASA launch/flight operations; a continuing overview of emerging range safety-related technologies; and status reports from all of the NASA Centers that have Range Safety responsibilities. Every effort has been made to include the most current information available. We recommend this report be used only for guidance and that the validity and accuracy of all articles be verified for updates. Once again the web-based format was used to present the annual report. We continually receive positive feedback on the web-based edition and hope you enjoy this year's product as well. As is the case each year, contributors to this report are too numerous to mention, but we thank individuals from the NASA Centers, the Department of Defense, and civilian organizations for their contributions. In conclusion, it has been a busy and productive year. I'd like to extend a personal Thank You to everyone who contributed to make this year a successful one, and I look forward to working with all of you in the upcoming year.

Dumont, Alan G.↗
NASA NTRS2016

Pilot Critical Incident Reports as a Means to Identify Human Factors of Remotely Piloted Aircraft

It has been estimated that aviation accidents are typically preceded by numerous minor incidents arising from the same causal factors that ultimately produced the accident. Accident databases provide in-depth information on a relatively small number of occurrences, however incident databases have the potential to provide insights into the human factors of Remotely Piloted Aircraft System (RPAS) operations based on a larger volume of less-detailed reports. Currently, there is a lack of incident data dealing with the human factors of unmanned aircraft systems. An exploratory study is being conducted to examine the feasibility of collecting voluntary critical incident reports from RPAS pilots. Twenty-three experienced RPAS pilots volunteered to participate in focus groups in which they described critical incidents from their own experience. Participants were asked to recall (1) incidents that revealed a system flaw, or (2) highlighted a case where the human operator contributed to system resilience or mission success. Participants were asked to only report incidents that could be included in a public document. During each focus group session, a note taker produced a de-identified written record of the incident narratives. At the end of the session, participants reviewed each written incident report, and made edits and corrections as necessary. The incidents were later analyzed to identify contributing factors, with a focus on design issues that either hindered or assisted the pilot during the events. A total of 90 incidents were reported. Human factor issues included the impact of reduced sensory cues, traffic separation in the absence of an out-the-window view, control latencies, vigilance during monotonous and ultra-long endurance flights, control station design considerations, transfer of control between control stations, the management of lost link procedures, and decision-making during emergencies. Pilots participated willingly and enthusiastically in the study, and generally had little difficulty recalling critical incidents. The results suggest that pilot interviews can be a productive method of gathering information on incidents that might not otherwise be reported. Some of the issues described in the reports have received significant attention in the literature, or are analogous to human factors of manned aircraft. In other cases, incident reports involved human factors that are poorly understood, and have not yet been the subject of extensive study. Although many of the reported incidents were related to pilot error, the participants also provided examples of the positive contribution that humans make to the operation of highly-automated systems.

unmanned aircraft systems↗
NASA NTRS2017

Relationship Between Carbon Dioxide Levels and Reported Congestion and Headaches on the International Space Station

Congestion is commonly reported during spaceflight, and most crewmembers have reported using medications for congestion during International Space Station (ISS) missions. Although congestion has been attributed to fluid shifts during spaceflight, fluid status reaches equilibrium during the first week after launch while congestion continues to be reported throughout long duration missions. Congestion complaints have anecdotally been reported in relation to ISS CO2 levels; this evaluation was undertaken to determine whether or not an association exists. METHODS: Reported headaches, congestion symptoms, and CO2 levels were obtained for ISS expeditions 2-31, and time-weighted means and single-point maxima were determined for 24-hour (24hr) and 7-day (7d) periods prior to each weekly private medical conference. Multiple imputation addressed missing data, and logistic regression modeled the relationship between probability of reported event of congestion or headache and CO2 levels, adjusted for possible confounding covariates. The first seven days of spaceflight were not included to control for fluid shifts. Data were evaluated to determine the concentration of CO2 required to maintain the risk of congestion below 1% to allow for direct comparison with a previously published evaluation of CO2 concentrations and headache. RESULTS: This study confirmed a previously identified significant association between CO2 and headache and also found a significant association between CO2 and congestion. For each 1-mm Hg increase in CO2, the odds of a crew member reporting congestion doubled. The average 7-day CO2 would need to be maintained below 1.5 mmHg to keep the risk of congestion below 1%. The predicted probability curves of ISS headache and congestion curves appear parallel when plotted against ppCO2 levels with congestion occurring at approximately 1mmHg lower than a headache would be reported. DISCUSSION: While the cause of congestion is multifactorial, this study showed congestion is associated with CO2 levels on ISS. Data from additional expeditions could be incorporated to further assess this finding. CO2 levels are also associated with reports of headaches on ISS. While it may be expected for astronauts with congestion to also complain of headaches, these two symptoms are commonly mutually exclusive. Furthermore, it is unknown if a temporal CO2 relationship exists between congestion and headache on ISS. CO2 levels were time-weighted for 24hr and 7d, and thus the time course of congestion leading to headache was not assessed; however, congestion could be an early CO2-related symptom when compared to headache. Future studies evaluating the association of CO2-related congestion leading to headache would be difficult due to the relatively stable daily CO2 levels on ISS currently, but a systematic study could be implemented on-orbit if desired.

Cole, Robert↗
DOE OSTI2023

Addendum 2 to the Closure Report for CAU 577 Area 5 Chromium Containing Waste Disposal Cells, NNSS, Nevada

Corrective Action Unit (CAU) 577, “Area 5 Chromium Containing Waste Disposal Cells,” includes five low-level waste cells at the Nevada National Security Site Area 5 Radioactive Waste Management Site where buried waste received from Nuclear Fuel Services, Inc., was subsequently determined to contain chromium that exceeded the toxicity characteristic leaching procedure regulatory limit, which would require the waste to carry hazardous waste code D007. CAU 577 was created to satisfy the requirements of the Settlement Agreement (SA) executed between the Nevada Division of Environmental Protection (NDEP) and the U.S. Department of Energy, National Nuclear Security Administration Nevada Field Office (NNSA/NFO) on April 25, 2019 (NDEP 2019). The SA required that the chromium-containing waste received from NFS would be addressed following the closure process laid out in the Federal Facility Agreement and Consent Order (FFACO). The FFACO process ensures proper closure of the chromium-containing waste and documentation of that closure through FFACO-type documents. The following three Corrective Action Sites (CASs) were closed, and their closure was documented in the Closure Report for Corrective Action Unit 577: Area 5 Chromium Containing Waste Disposal Cells, Nevada National Security Site, Nevada, DOE/EMNV--0030, dated September 2021 (U.S. Department of Energy [DOE] Environmental Management [EM] Nevada Program 2021a): • CAS 05-21-02, Waste Disposal Cell 12 • CAS 05-21-03, Waste Disposal Cell 15 • CAS 05-21-04, Waste Disposal Cell 17 Closure of the following CAS was previously documented in the Addendum to the Closure Report for Corrective Action Unit 577: Area 5 Chromium Containing Waste Disposal Cells, Nevada National Security Site, Nevada, DOE/EMNV--0030-ADD, dated September 2022 (DOE EM Nevada Program 2022): • CAS 05-21-05, Waste Disposal Cell 20 This second addendum to the Closure Report documents the closure activities that have occurred for CAS 05-21-06, Waste Disposal Cell 21. This is the last CAS in CAU 577. The final waste shipment was placed in the waste disposal cell on November 21, 2022. Following this, closure activities began on November 28, 2022, and were conducted according to the Corrective Action Decision Document/Corrective Action Plan (CADD/CAP) for CAU 577 (DOE EM Nevada Program 2021b). The following closure activities were performed: • Constructing an engineered evapotranspiration cover • Installing two subsidence monuments and vadose zone monitoring equipment • Seeding the cover with a mixture of native plant species • Installing four concrete monuments on the corners of the cover and placing two use restriction (UR) warning signs on each monument These activities fulfill applicable federal and state regulations for closure of CAS 05-21-06 and minimize potential future exposure pathways to buried waste. Completed closure activities are also consistent with closure of the nine historical Resource Conservation and Recovery Act (RCRA) units included in Section 10.2.2 of the RCRA Permit that governs hazardous waste management activities at the Nevada National Security Site (Permit NEV HW0101) (NDEP 2023). UR documentation for this CAS is included in Appendix B of this report. The post-closure plan is presented in detail in the CADD/CAP for CAU 577 (DOE EM Nevada Program 2021b), and the requirements are summarized in Section 5.2 of this document. In accordance with paragraph 5D of the SA, a request to incorporate the requirements for post-closure monitoring of CAU 577 was included with the permit application for RCRA Permit NEV HW0101 that was submitted in January 2022 (NNSA/NFO 2022). The request included the post-closure requirements for the three CASs that had been closed at the time of submittal of the application as well as requirements that would be implemented upon future approval of closure of the remaining two CASs. All CAU 577 post-closure monitoring requirements have been captured in the April 4, 2023, Revision 7 of the RCRA Permit (NDEP 2023). As the RCRA Permit NEV HW0101 has been revised since the submittal of the original CAU 577 Closure Report (DOE EM Nevada Program 2021a) and Addendum 1 (DOE EM Nevada Program 2022), the post-closure requirements in this Addendum 2 report do not align with the previous documents. Specific changes resulting from the issuance of Revision 7 of the RCRA Permit are discussed in Section 5.2 of this report. The requirements in this report are consistent with the current permit (NDEP 2023) and supersede all requirements listed in the CAU 577 Closure Report and Addendum 1. All CAU 577 post-closure requirements should be conducted in accordance with the version of the RCRA Permit that is current at the time of the activities being performed. The DOE EM Nevada Program is requesting a Notice of Completion from NDEP for closure of CAU 577. Although CAU 577 is not a legacy site, the FFACO process is being followed to ensure proper closure of the chromium-containing waste. Therefore, transfer of CAU 577 from Appendix III of the FFACO to Appendix IV, Closed Corrective Action Units, is requested, as all closure activities have been completed.

12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗
DOE OSTI2015

Groundwater monitoring report streamlining techniques - 15305

Compliance with national and state environmental regulations (e.g. RCRA and CERCLA [SuperFund] requires Savannah River Site (SRS) to extensively collect and report groundwater monitoring data, with potential fines for missed reporting deadlines. Large reports, which may contain dozens to hundreds of monitoring stations, are especially challenging to present data in a way that is quick and easy to interpret. Initially analyzing hundreds to thousands of records of data to be summarized in the report can be daunting, and producing maps can be extremely time consuming. Several utilities have been developed at SRS to facilitate production of the regulatory reports which include data tables, charts, maps, and cross-sections. Components of each report are generated in accordance with complex sets of regulatory requirements specific to each site monitored. SRS developed a relational database to incorporate the detailed reporting rules with the groundwater data, and created a set of automation tools to interface with the information and generate the report components. Maps produced with ArcGIS use a technique that can be repeatedly used to display data very quickly and in a consistent form. Cross-sections developed with RockWorks provide a more technical and geological analysis and representation of well and boring data, while allowing for automated data placement. These process improvements have streamlined the repetitive job of creating data tables, charts, maps, and cross-sections. It has also enhanced report quality and consistency by centralizing the information, and has reduced manpower and production time through automated efficiencies. (authors)

12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗
DOE OSTI2014

Nevada National Security Site Environmental Report 2013

This report was prepared to meet the information needs of the public and the requirements and guidelines of the U.S. Department of Energy (DOE) for annual site environmental reports. It was prepared by National Security Technologies, LLC (NSTec), for the U.S. Department of Energy, National Nuclear Security Administration Nevada Field Office (NNSA/NFO) (formerly designated as the Nevada Site Office [NNSA/NSO]). The new field office designation occurred in March 2013. Published reports cited in this 2013 report, therefore, may bear the name or authorship of NNSA/NSO. This and previous years’ reports, called Annual Site Environmental Reports (ASERs), Nevada Test Site Environmental Reports (NTSERs), and, beginning in 2010, Nevada National Security Site Environmental Reports (NNSSERs), are posted on the NNSA/NFO website at http://www.nv.energy.gov/library/publications/aser.aspx.

54 ENVIRONMENTAL SCIENCES↗
DOE OSTI2015

Post-Closure Report for Closed Resource Conservation and Recovery Act Corrective Action Units, Nevada National Security Site, Nevada, for Fiscal Year 2014

This report serves as the combined annual report for post-closure activities for several Corrective Action Units (CAUs). The locations of the sites are shown in Figure 1. This report covers fiscal year 2014 (October 2013–September 2014). The post-closure requirements for these sites are described in Resource Conservation and Recovery Act Permit Number NEV HW0101 and summarized in each CAU-specific section in Section 1.0 of this report. The results of the inspections, a summary of maintenance activities, and an evaluation of monitoring data are presented in this report. Site inspections are conducted semiannually at CAUs 90 and 91 and quarterly at CAUs 92, 110, 111, and 112. Additional inspections are conducted at CAU 92 if precipitation occurs in excess of 0.50 inches (in.) in a 24-hour period and at CAU 111 if precipitation occurs in excess of 1.0 in. in a 24-hour period. Inspections include an evaluation of the condition of the units, including covers, fences, signs, gates, and locks. In addition to visual inspections, soil moisture monitoring, vegetation evaluations, and subsidence surveys are conducted at CAU 110. At CAU 111, soil moisture monitoring, vegetation evaluations, subsidence surveys, direct radiation monitoring, air monitoring, radon flux monitoring, and groundwater monitoring are conducted. The results of the vegetation surveys and an analysis of the soil moisture monitoring data at CAU 110 are presented in this report. Results of additional monitoring at CAU 111 are documented annually in the Nevada National Security Site Waste Management Monitoring Report Area 3 and Area 5 Radioactive Waste Management Sites and in the Nevada National Security Site Data Report: Groundwater Monitoring Program Area 5 Radioactive Waste Management Site, which will be prepared in approximately June 2015. All required inspections, maintenance, and monitoring were conducted in accordance with the post-closure requirements of the permit. It is recommended to continue inspections and monitoring as scheduled.

12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗
DOE OSTI2017

Underground Test Area October 1, 2015, to December 31, 2016 Quality Assurance Report Nevada National Security Site, Nevada

This report is required by the Underground Test Area (UGTA) Activity Quality Assurance Plan (QAP) (NNSA/NFO, 2015) and identifies the UGTA quality assurance (QA) activities from October 1, 2015, through December 31, 2016 (hereafter, called “the reporting period”). This expanded reporting period allows this report to be converted to a calendar-year (CY) reporting cycle. This change is being made to better align this report with the annual UGTA sampling and the Nevada National Security Site (NNSS) environmental reports. All UGTA organizations—U.S. Department of Energy (DOE) Office of Environmental Management (EM) Nevada Program; Desert Research Institute (DRI); Lawrence Livermore National Laboratory (LLNL); Los Alamos National Laboratory (LANL); National Security Technologies, LLC (NSTec); Navarro Research and Engineering, Inc. (Navarro); and the U.S. Geological Survey (USGS)—conducted QA activities in the reporting period. The activities included conducting oversight assessments for QAP compliance, identifying findings and completing corrective actions, evaluating laboratory performance, reviewing technical work, and publishing documents.

12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗
NASA NTRS2013

2013 NASA Range Safety Annual Report

Welcome to the 2013 edition of the NASA Range Safety Annual Report. Funded by NASA Headquarters, this report provides an Agency overview for current and potential range users. This report contains articles which cover a variety of subject areas, summaries of various activities performed during the past year, links to past reports, and information on several projects that may have a profound impact on the way business will be conducted in the future. Specific topics discussed in the 2013 NASA Range Safety Annual Report include a program overview and 2013 highlights, Range Safety Training, Independent Assessments, support to Program Operations at all ranges conducting NASA launch/flight operations, a continuing overview of emerging range safety-related technologies, and status reports from all of the NASA Centers that have Range Safety responsibilities. Every effort has been made to include the most current information available. We recommend this report be used only for guidance and that the validity and accuracy of all articles be verified for updates. As is the case each year, we had a wide variety of contributors to this report from across our NASA Centers and the national range safety community at large, and I wish to thank them all. On a sad note, we lost one of our close colleagues, Dr. Jim Simpson, due to his sudden passing in December. His work advancing the envelope of autonomous flight safety systems software/hardware development leaves a lasting impression on our community. Such systems are being flight tested today and may one day be considered routine in the range safety business. The NASA family has lost a pioneer in our field, and he will surely be missed. In conclusion, it has been a very busy and productive year, and I look forward to working with all of you in NASA Centers/Programs/Projects and with the national Range Safety community in making Flight/Space activities as safe as they can be in the upcoming year.

Center Status↗
DOE OSTI2018

Improving compliance with Intersocietal Accreditation Commission (IAC) reporting standards: A serial comparison of 523 labs over seven years

Background: The aim of this study was to evaluate reporting compliance of laboratories applying for serial accreditation by the Intersocietal Accreditation Commission (IAC) and compare compliance based on laboratory characteristics. Methods: All laboratories applying for IAC accreditation for the first time in 2008 and then twice more (2011-2014) were evaluated for compliance with 18 reporting elements. The elements were ranked into three severity groups (high/moderate/low). Results: Reports from 523 laboratories were evaluated. The percentage of laboratories with reporting issues by cycle was 66.2% for cycle 1, 36.7% for cycle 2, and 43.8% for cycle 3 (p < .001). For most of the 18 elements, there was a significant decrease in the percentage of labs with issues. Less moderate and high severity errors were seen over time. Also, the mean non-compliant elements per laboratory decreased from 5.78 ± 2.72 at cycle 1, down to 1.25 ± 1.77 at cycle 3. Conclusions: In facilities applying for 3 consecutive IAC accreditation cycles, reporting compliance with IAC Standards improved between cycles 1-2 and 1-3. No significant improvement occurred between cycles 2-3. Although the quality of reports improved overall, problems remain in quantifying myocardial perfusion defects, documenting report approval date, and integrating stress and imaging reports.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
DOE OSTI2014

A Real-Time Safety and Quality Reporting System: Assessment of Clinical Data and Staff Participation

Purpose: To report on the use of an incident learning system in a radiation oncology clinic, along with a review of staff participation. Methods and Materials: On September 24, 2010, our department initiated an online real-time voluntary reporting system for safety issues, called the Radiation Oncology Quality Reporting System (ROQRS). We reviewed these reports from the program's inception through January 18, 2013 (2 years, 3 months, 25 days) to assess error reports (defined as both near-misses and incidents of inaccurate treatment). Results: During the study interval, there were 60,168 fractions of external beam radiation therapy and 955 brachytherapy procedures. There were 298 entries in the ROQRS system, among which 108 errors were reported. There were 31 patients with near-misses reported and 27 patients with incidents of inaccurate treatment reported. These incidents of inaccurate treatment occurred in 68 total treatment fractions (0.11% of treatments delivered during the study interval). None of these incidents of inaccurate treatment resulted in deviation from the prescription by 5% or more. A solution to the errors was documented in ROQRS in 65% of the cases. Errors occurred as repeated errors in 22% of the cases. A disproportionate number of the incidents of inaccurate treatment were due to improper patient setup at the linear accelerator (P<.001). Physician participation in ROQRS was nonexistent initially, but improved after an education program. Conclusions: Incident learning systems are a useful and practical means of improving safety and quality in patient care.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
DOE OSTI2017

Dosimetric Predictors of Patient-Reported Xerostomia and Dysphagia With Deintensified Chemoradiation Therapy for HPV-Associated Oropharyngeal Squamous Cell Carcinoma

Purpose/Objective(s): To estimate the association between different dose-volume metrics of the salivary glands and pharyngeal constrictors with patient reported severity of xerostomia/dysphagia in the setting of deintensified chemoradiation therapy (CRT). Methods and Materials: Forty-five patients were treated on a phase 2 study assessing the efficacy of deintensified CRT for favorable-risk, HPV-associated oropharyngeal squamous cell carcinoma. Patients received 60 Gy intensity modulated radiation therapy with concurrent weekly cisplatin (30 mg/m{sup 2}), and reported the severity of their xerostomia/dysphagia (before and after treatment) using the patient-reported outcome version of the Common Terminology Criteria for Adverse Events (CTCAE) (PRO-CTCAE). Individual patient dosimetric data of the contralateral parotid and submandibular glands and pharyngeal constrictors were correlated with changes in PRO-CTCAE severity. A change in severity (from baseline) of ≥2 was considered clinically meaningful. Associations between dose-volume metrics and patient outcomes were assessed with receiver operating characteristic (ROC) curve and logistic regression model. Results: Six months after CRT, patients reporting <2 change in xerostomia severity (n=14) had an average D{sub mean} = 22 ± 9 Gy to the sum of the contralateral glands (parotid + submandibular) compared with the patients reporting ≥2 change (n=21), who had an average D{sub mean} = 34 ± 8 Gy. V15 to V55 for the combined contralateral glands showed the strongest association with xerostomia (area under the curve [AUC] = 0.83-0.86). Based on the regression analysis, a 20% risk of toxicity was associated with V15 = 48%, V25 = 30%, and D{sub mean}=21 Gy. Six months after CRT, patients reporting <2 change in dysphagia severity (n=26) had an average V55 = 76 ± 13 (%) to the superior pharyngeal constrictor compared with the patients reporting ≥2 change in severity (n=9), who had average V55 = 89 ± 13 (%). V55to V60 had the strongest association with dysphagia (AUC = 0.70-0.75). Based on the regression analysis, a 20% risk of toxicity was associated with V55 = 78%, V60 = 40%. The findings at 12 months were similar. Conclusions: After deintensified CRT, the rate of patient-reported xerostomia/dysphagia appears to be associated with the V15 of the combined contralateral salivary glands and V55 to V60 of the superior pharyngeal constrictors.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
DOE OSTI2023

Fluorescent and Bioluminescent Reporter Mouse-Adapted Ebola Viruses Maintain Pathogenicity and Can Be Visualized in Vivo

Abstract Ebola virus (EBOV) causes lethal disease in humans but not in mice. Here, we generated recombinant mouse-adapted (MA) EBOVs, including 1 based on the previously reported serially adapted strain (rMA-EBOV), along with single-reporter rMA-EBOVs expressing either fluorescent (ZsGreen1 [ZsG]) or bioluminescent (nano-luciferase [nLuc]) reporters, and dual-reporter rMA-EBOVs expressing both ZsG and nLuc. No detriment to viral growth in vitro was seen with inclusion of MA-associated mutations or reporter proteins. In CD-1 mice, infection with MA-EBOV, rMA-EBOV, and single-reporter rMA-EBOVs conferred 100% lethality; infection with dual-reporter rMA-EBOV resulted in 73% lethality. Bioluminescent signal from rMA-EBOV expressing nLuc was detected in vivo and ex vivo using the IVIS Spectrum CT. Fluorescent signal from rMA-EBOV expressing ZsG was detected in situ using handheld blue-light transillumination and ex vivo through epi-illumination with the IVIS Spectrum CT. These data support the use of reporter MA-EBOV for studies of Ebola virus in animal disease models.

Immunology↗
DOE OSTI2020

Accuracy of self‐reported weight, height and body mass index among older people in Japan

Aim Weight and height are usually self‐reported in population‐based epidemiological surveys. While the accuracy of self‐reports has been extensively studied in younger populations, less is known in older populations. We investigated the accuracy of self‐reported weight, height and body mass (BMI) in an older cohort in Japan, where overweight/obesity and underweight coexist. Methods We used data from older Japanese adults (≥65 years) participating in the Japan Gerontological Evaluation Study in 2016 to 2017 (7357 men and 9271 women). Self‐report data were linked to objective data obtained from clinical examinations. Results The mean ± standard deviation (SD) age was 74.5 ± 5.8 years, mean ± SD weight, height and BMI were 55.7 ± 10.1 kg, 156.0 ± 8.9 cm and 22.8 ± 3.1, respectively. Results showed high intraclass correlation coefficients for self‐reported and measured values (0.97 for weight; 0.96 for height). While weight/height were overestimated among men (weight by 0.096 kg; height by 0.27 cm) and women (weight by 0.18 kg; height by 0.27 cm), BMI tended to be slightly underestimated (−0.034 kg/m 2 for men; −0.037 kg/m 2 for women). However, the absolute differences between self‐reported and measured values were not negligible; people had a higher risk for both under‐ and overestimation of their BMI category with increasing age. Lower education predicted BMI overestimation, whereas lower income predicted BMI underestimation. Conclusions Overall accuracy of self‐reported body habitus was higher in this cohort of older Japanese compared with previous reports. Nevertheless, misclassification of BMI due to the misreporting of their weight/height was more common among the oldest‐old, as well as those with lower education and income. Geriatr Gerontol Int 2020; 20: 803–810 .

Yazawa, Aki↗
DOE OSTI2014

MO-F-16A-04: Case Study: Estimation of Peak Skin Dose Following a Physician Reported “High Dose” Case and Sentinel Event Considerations

Purpose: This work offers as a teaching example a reported high dose fluoroscopy case and the workflow the institution followed to self-report a radiation overdose sentinel event to the Joint Commission. Methods: Following the completion of a clinical case in a hybrid OR room with a reported air kerma of >18 Gy at the Interventional Reference Point (IRP) the physicians involved in the case referred study to the institution's Radiation Safety Committee (RSC) for review. The RSC assigned a Diagnostic Medical Physicist (DMP) to estimate the patient's Peak Skin Dose (PSD) and analyze the case. Following the DMP's analysis and estimate of a PSD of >15 Gy the institution's adverse event committee was convened to discuss the case and to self-report the case as a radiation overdose sentinel event to the Joint Commission. The committee assigned a subgroup to perform the root cause analysis and develop institutional responses to the event. Results: The self-reporting of the sentinel event and the associated root cause analysis resulted in several institutional action items that are designed to improve process and safety. A formal reporting and analysis mechanism was adopted to review fluoroscopy cases with air kerma greater than 6 Gy at the IRP. An improved and formalized radiation safety training program for physicians using fluoroscopy equipment was implemented. Additionally efforts already under way to monitor radiation exposure in the Radiology department were expanded to include all fluoroscopy equipment capable of automated dose reporting. Conclusion: The adverse event review process and the root cause analysis following the self-reporting of the sentinel event resulted in policies and procedures that are expected to improve the quality and safe usage of fluoroscopy throughout the institution.

60 APPLIED LIFE SCIENCES↗