Valve Failure During Patient Treatment with Gamma Stereotactic Radiosurgery UnitML031060184 |
Person / Time |
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Site: |
Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant ![Entergy icon.png](/w/images/7/79/Entergy_icon.png) |
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Issue date: |
05/11/1995 |
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From: |
Cool D NRC/NMSS/IMNS |
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To: |
|
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References |
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IN-95-025, NUDOCS 9505050171 |
Download: ML031060184 (9) |
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Similar Documents at Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant |
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Category:NRC Information Notice
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Mclaughlin on NRC, Regarding NRC Information Notice 2006-13: Groundwater Contamination 2020-09-03 The following query condition could not be considered due to this wiki's restrictions on query size or depth: <code> [[:Beaver Valley]] OR [[:Millstone]] OR [[:Hatch]] OR [[:Monticello]] OR [[:Calvert Cliffs]] OR [[:Dresden]] OR [[:Davis Besse]] OR [[:Peach Bottom]] OR [[:Browns Ferry]] OR [[:Salem]] OR [[:Oconee]] OR [[:Mcguire]] OR [[:Nine Mile Point]] OR [[:Palisades]] OR [[:Palo Verde]] OR [[:Perry]] OR [[:Indian Point]] OR [[:Fermi]] OR [[:Kewaunee]] OR [[:Catawba]] OR [[:Harris]] OR [[:Wolf Creek]] OR [[:Saint Lucie]] OR [[:Point Beach]] OR [[:Oyster Creek]] OR [[:Watts Bar]] OR [[:Hope Creek]] OR [[:Grand Gulf]] OR [[:Cooper]] OR [[:Sequoyah]] OR [[:Byron]] OR [[:Pilgrim]] OR [[:Arkansas Nuclear]] OR [[:Three Mile Island]] OR [[:Braidwood]] OR [[:Susquehanna]] OR [[:Summer]] OR [[:Prairie Island]] OR [[:Columbia]] OR [[:Seabrook]] OR [[:Brunswick]] OR [[:Surry]] OR [[:Limerick]] OR [[:North Anna]] OR [[:Turkey Point]] OR [[:River Bend]] OR [[:Vermont Yankee]] OR [[:Crystal River]] OR [[:Haddam Neck]] OR [[:Ginna]] OR [[:Diablo Canyon]] OR [[:Callaway]] OR [[:Vogtle]] OR [[:Waterford]] OR [[:Duane Arnold]] OR [[:Farley]] OR [[:Robinson]] OR [[:Clinton]] OR [[:South Texas]] OR [[:San Onofre]] OR [[:Cook]] OR [[:Comanche Peak]] OR [[:Yankee Rowe]] OR [[:Maine Yankee]] OR [[:Quad Cities]] OR [[:Humboldt Bay]] OR [[:La Crosse]] OR [[:Big Rock Point]] OR [[:Rancho Seco]] OR [[:Zion]] OR [[:Midland]] OR [[:Bellefonte]] OR [[:Fort Calhoun]] OR [[:FitzPatrick]] OR [[:McGuire]] OR [[:LaSalle]] OR [[:Fort Saint Vrain]] OR [[:Shoreham]] OR [[:Satsop]] OR [[:Trojan]] OR [[:Atlantic Nuclear Power Plant]] </code>.
[Table view]The following query condition could not be considered due to this wiki's restrictions on query size or depth: <code> [[:Beaver Valley]] OR [[:Millstone]] OR [[:Hatch]] OR [[:Monticello]] OR [[:Calvert Cliffs]] OR [[:Dresden]] OR [[:Davis Besse]] OR [[:Peach Bottom]] OR [[:Browns Ferry]] OR [[:Salem]] OR [[:Oconee]] OR [[:Mcguire]] OR [[:Nine Mile Point]] OR [[:Palisades]] OR [[:Palo Verde]] OR [[:Perry]] OR [[:Indian Point]] OR [[:Fermi]] OR [[:Kewaunee]] OR [[:Catawba]] OR [[:Harris]] OR [[:Wolf Creek]] OR [[:Saint Lucie]] OR [[:Point Beach]] OR [[:Oyster Creek]] OR [[:Watts Bar]] OR [[:Hope Creek]] OR [[:Grand Gulf]] OR [[:Cooper]] OR [[:Sequoyah]] OR [[:Byron]] OR [[:Pilgrim]] OR [[:Arkansas Nuclear]] OR [[:Three Mile Island]] OR [[:Braidwood]] OR [[:Susquehanna]] OR [[:Summer]] OR [[:Prairie Island]] OR [[:Columbia]] OR [[:Seabrook]] OR [[:Brunswick]] OR [[:Surry]] OR [[:Limerick]] OR [[:North Anna]] OR [[:Turkey Point]] OR [[:River Bend]] OR [[:Vermont Yankee]] OR [[:Crystal River]] OR [[:Haddam Neck]] OR [[:Ginna]] OR [[:Diablo Canyon]] OR [[:Callaway]] OR [[:Vogtle]] OR [[:Waterford]] OR [[:Duane Arnold]] OR [[:Farley]] OR [[:Robinson]] OR [[:Clinton]] OR [[:South Texas]] OR [[:San Onofre]] OR [[:Cook]] OR [[:Comanche Peak]] OR [[:Yankee Rowe]] OR [[:Maine Yankee]] OR [[:Quad Cities]] OR [[:Humboldt Bay]] OR [[:La Crosse]] OR [[:Big Rock Point]] OR [[:Rancho Seco]] OR [[:Zion]] OR [[:Midland]] OR [[:Bellefonte]] OR [[:Fort Calhoun]] OR [[:FitzPatrick]] OR [[:McGuire]] OR [[:LaSalle]] OR [[:Fort Saint Vrain]] OR [[:Shoreham]] OR [[:Satsop]] OR [[:Trojan]] OR [[:Atlantic Nuclear Power Plant]] </code>. |
v1A I . -
UNITED STATES
NUCLEAR REGULATORY CONMISSION
OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS
WASHINGTON, D.C. 20555 May 11, 1995 NRC INFORMATION NOTICE 95-25: VALVE FAILURE DURING PATIENT TREATMENT WITH
GAMMA STEREOTACTIC RADIOSURGERY UNIT
gAd-!ressees
All U.S. Nuclear Regulatory Comission Medical Licensees.
Purpose
The U.S. Nuclear Regulatory Commission (NRC)inwhich is issuing this information
notice to alert addressees to an incident the patient couch of a
Leksell Gam System Model 23016 ('ganna knife*) unit failed to retract from
the treatment position because of a failure of a two-position solenoid- operated valve on the hydraulic system of the unit. It is expected that
recipients will review the information foravoid applicability to their facilities
and consider actions, as appropriate, to noticesimilar problems. However, suggestions contained inthis information response isrequired.are not new NRC requirements;
therefore, no specific action nor written
Descriotion of Circumstances
NRC was notified of an incident that occurred at an Agreement State licensee
inwhich a patient undergoing gamma stereotactic radiosurgery received a dose, for a single fraction, that was 127 percent greater than the dose prescribed
for that fraction. On October 25, 1994, a System patient was prescribed to receive a
series of 10 exposures ina Leksell Gamna the patient Model 23016 f"gamna knife*)
unit. At the end of the sixth exposure, couch f i1ed to retract
of failure of a two-. tion, solenoid- from the treatment position because a
of the unit.
operated valve on the hydraulic system
The licensee's staff attempted to: (I)manually pump the hydraulic system;
and (2) shut the unit off. The latter action would normally turn the pump on
and direct the pressure to allow the bed to retract. However, inthis case, and the Internal spring could not
the valve was stuck inthe 'bed-in' positionThe valve failure disabled both the
reset the valve to allow the bed to move. on the unit, resulting
normal and primary emergency patient retraction systems
3.8 minutes longer than the intended
Inthe patient being irradiated forpersonnel
3-minute treatment time. Medical entered the room, pulled a
were able to move the bed
pressure equalization latch on the bed, and Subsequently, approximately 50 centimeters (20 inches). remove the patient they manually
from the treatment
disconnected the helmet from the unit to of the
room. The U.S. distributor, Elekta Radiosurgery,distributor notified
Inc., was
also notified all
event and subsequently replaced the valve. itThe to a valve failure, with no
Its customers of the event and attributed
specific information on the cause of the failure.
9505050171 A ,
I NO -F
mIs_1 o
As1.R*. .
IN 95-25
'lay 11, 1995 At the request of the State of Georgia (Elekta Radlosurgery, Engineering Inc., is located
in Georgia), NRC, through a contract with the Idaho National The INEL
Laboratory (IEL), conducted a root-cause analysis of the incident. physicist, medical
team was comprised of a mechanical engineer, risk analyst, and radiation oncologist.
Discussin
The findings of the INEL report indicate that the cause offluid the valve failure
contaminants in the hydraulic system, which
was the existence of metal or scored the
either became caught between the valve spool and valve body It appears that
spool, thereby locking the valve in the bed-in' position. and rubber
during installation, several months before, pieces of dirt, metal, cleaned from
that are typically found in new hydraulic hoses were not properly
that were
one of the hoses. The report concluded that otheraremachines less likely to have a
installed before and have been cycled repeatedly a concern for the
similar failure; however, this type of failure remains
installation of new machines.
the
When the patient couch failed to retract, the facility staff toreleased the lowest
latch at the foot of the couch, thereby dropping the helmet When the helmet
position corresponding to the low point of the couch track.
of the primary
Is at the low point, the maximum dose rate at the focus percent of the dose rate at
10
collimator through the helmet is approximately alignment
the treatment position because of the lack of with the helmet
openings. Although the one exposure delivered a 127 percent overdose, it was
of the complete target volume with the result
delivered to a partial volume target within the
that there was a slight increase in the percentage of the
minor at the
45 percent isodose. However, changes in the isodose contour were to the patient
20 percent isodose contour. The maximum total dose delivered (fractions),
was approximately 33.5 Gray (Gy) (3350 rads) forrads), all 10 exposures
dose of 33.33 Gy (3333 therefore the medical
compared with a planned it appears that the
consequences of this incident are minimal. Furthermore, received less than 0.03 mSv
medical staff who responded to the emergency all
(3 mrem) each.
The report provides several recommendations: 1) to further the reduce the
failure of the kind experienced at facility, any
possibility of a repeat filter;
proposed design change should include installation of a 20-micronnew unit
2) a one-time laboratory analysis of hydraulic fluid after each
gamma knife
installation in addition to such analysis of, at least five other obtain a second
users should
units currently in operation; 3) all gamma knife the unit; 4) all gamma knife
emergency tool to disengage the head frame from
procedures to ensure they include
users should review their emergency
provisions in the event the bed fails to retract; and 5) review and retraining
of all emergency procedures with operating staff.
- w.
IN 95-25 May 11, 1995 are requested to submit
As part of the licensing process, license applicants radiation exposure of
procedures for emergencies which could result in procedures for the gama
patients, workers, and the general public. Emergency
the hydraulic pressure is within
knife unit should address situations in which retract when the timer reaches
normal operating range, but the bed fails to should include procedures for
0.0. In addition, the emergency procedures the housing, using the long-handled
releasing the helmet from the trunnions in who may be installing
emergency tools provided by the manufacturer. Licensees for contamination of the
a gamma knife unit should be aware of the potential
hydraulic fluid.
nor written response. If
This information notice requires no specific action this notice, please contact
you have any questions about the information in NRC regional office.
the technical contact listed below, or the appropriate
Donald A. Cool, Director
Oisin of Industrial and
dical Nuclear Safety
Office of Nuclear Material
Safety and Safeguards
Technical contact: Patricia K. Holahan, NMSS
(301) 415-7847 Attachments:
Notices
1. List of Recently Issued NMSS Information Notices
2. 1ist of Recently Issued NRC Information
K>
Attachment 1 IN 95-25 may 11. 1995 tI-. ';: I Page I of I
I - !~
..
LIST OF RECENTLY ISSUED
WSS INFORMATION NOTICES
.. in-formation Date of
,~
Subject Issuance Issued to
_o.c No.
tNotice No
- ..
Reactivity Insertion 04/06/95 All holders of OLs or CPs
94-64, for nuclear power reactors.
Supp. 1 Transient and Accident
Limits for High Burnup
Fuel
Radiopharmaceutical Vial 01/27/95 All U.S. Nuclear Regulatory
95-07 Commission medical licensees
Breakage during Preparation authorized to use byproduct
material for diagnostic
procedures.
DOT Safety Advisory: 01/04/95 All U.S. Nuclear Regulatory
95-01 Commission licensees.
High Pressure Aluminum
Seamless and Aluminum
Composite Hoop-Wrapped
Cylinders
Equipment Failures at 12/28/94 All U.S. Nuclear Regulatory
94-89 Commission Irradiator
Irradiator Facilities 1icensees.
Unauthorized Transfer of 12/07/94 All fuel cycle and material
89-25, licensees.
Rev. 1 Ownership or Control of
Licensed Activities
Accuracy of Bioassay 11/25/94 All U.S. Nuclear Regulatory
94-81 Commission licensees.
and Environmental
Sapling Results
Reporting Fuel Cycle 10/20/94 All 10 CFR Part 70
93-60, fuel cycle licensees.
Supp. 1 and Materials Events to
the NRC Operations Center
Facility Managefent 10/13/94 All U.S. Nuclear Regulatory
94-74 Commission Medical
Responsibilities for
Purchased or Contracted Licensees.
Services for Radiation
Therapy Programs
K)
Attachment 2 IN 95-25 May 11, 1995 Page I of I
LIST OF RECENTLY ISSUED
NRC INFORMATION NOTICES
information Date of
Notice No. Subject Issuance Issued to
Summary of Licensed 04/25/95 All holders of OLs or CPs
95-24 for nuclear power reactors.
Operator Requalification
Inspection Program
Findings
Control Room Staffing 04/24/95 All holders of OLs or CPs
95-23 for nuclear power reactors
Below minimum Regulatory and all licensed operators
Requirements and senior operators at
those reactors.
Hardened or Contaminated 04/21/95 All holders of OLs or CPs
95-22 for nuclear power reactors.
Lubricants Cause Metal
Clad Circuit Breaker
Failures
Unexpected Degradation 04/20/95 All holders of OLs or CPs
95-21 for nuclear power reactors.
of Lead Storage Batteries
Reactivity Insertion 04/06/95 All holders of OLs or CPs
94-64, for nuclear power reactors
Supp. 1 Transient and Accident
Limits for High Burnup
Fuel
Potential Pressure-Locking 03/31/95 All holders of OLs or CPs
95-18. for nuclear power reactors.
Supp. I of Safety-Related Power- Operated Gate Valves
Failures in Rosemount 03/22/95 All holders of OLs or CPs
95-20 for nuclear power reactors.
Pressure Transmitters
due to Hydrogen Per- meation into the Sensor
Cell
Failure of Reactor Trip 03/22/95 All holders of OLs or CPs
95-19 for nuclear power reactors.
Breaker to Open Because
of Cutoff Switch Material
Lodged in the Trip Latch
Mechanism
OL
CP
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IN 95-25 May 11, 1995 As part of the licensing process, license applicants are requested to submit
procedures for emergencies which could result in radiation exposure of
patients, workers, and the general public. Emergency procedures for the gamma
knife unit should address situations in which the hydraulic pressure is within
normal operating range, but the bed fails to retract when the timer reaches
0.0. In addition, the emergency procedures should include procedures for
releasing the helmet from the trunnions in the housing, using the long-handled
emergency tools provided by the manufacturer. Licensees who may be installing
a gauma knife unit should be aware of the potential for contamination of the
hydraulic fluid.
This information notice requires no specific action nor written response. If
you have any questions about the information in this notice, please contact
the technical contact listed below, or the appropriate NRC regional office.
Donald A. Cool, Director
Division of Industrial and
Medical Nuclear Safety
Office of Nuclear Material
Safety and Safeguards
Technical contact: Patricia K. Holahan, NMSS
(301) 415-7847 Attachments:
1. List of Recently Issued NHSS Information Notices
2. List of Recently Issued NRC Information Notices
DOC NAME: 95-25.IN
To receiw a COpy of this docuent, Indicate In the box CwCopy w/o attchment/enctosure EnCopy wilth attchmentlenctosure K a go cwpy
OFFICE IMAB* IMAB* IMAB* Tech Ed*
NAME PKHolahan JMPiccone LWCamper EKraus
DATE 03/01/9Si n 03/27/95 03/30/95 03/10195 OFFICE IMOB* OSP* OGC* DD ESMNSI
NME FCCombs RLBangart STreby EWBrach
DATE 04/20/95 04/27/95 05/03/95 OFFICE D/IMNS*
HME DACool
DATE 05/03/95
I
IN 95- may , 1995 are requested to submit
As part of the licensing process, license applicants in radiation exposure of
procedures for emergencies which could resultEmergency procedures for the gamma
patients, workers, and the general public. pressure Is within
knife unit should address situations in which the hydraulic
normal operating range, but the bed fails to should retract when the timer reaches
Include procedures for
O.0. In addition, the emergency procedures using the long-handled
releasing the helmet from the trunnions in the housing, who may be installing
emergency tools provided by the manufacturer. Licensees for contamination of the
a gamma knife unit should be aware of the potential
hydraulic fluid.
nor written response. If
This information notice requires no specific action notice, please contact
you have any questions about the information in this NRC regional office.
the technical contact listed below, or the appropriate
Donald A. Cool, Director
Division of Industrial and
Medical Nuclear Safety
Office of Nuclear Material
Safety and Safeguards
Technical contact: Patricia K. Holahan, NMSS
(301) 415-7347 Attachments:
1. List of Recently Issued NMSS Information Notices
2. List of Recently Issued NRC Information Notices
' e s _. ^^^. . _
r____o..
OFC I B IMAB* Tech Ed
JMPiccone LWCamper EKraus
NANE PKfl ahan
DATE /9S_ 03/27 95 _ 03/30/95 03/10/95 j
I0FC ISOB* o P* I OGC* l UA D/IMNS
RLBangart STreby ch IM1ool
NAME FCCombs
DATE 04/12/95 04/20/95 0/29/955 Ater a c a~I Uu N fl LAPY
-
C a UUVLK L * tUWVLK R &nM&VV~n1 ,, _ ,._ _. .
IN 95- April , 1995 Emergency procedures, for the gamma knife unit, should address ituations in
which the hydraulic pressure is within normal operatIng rang e , but the bed
fails to retract when the timer reaches 0.0. In addition, emergency
procedures should include procedures for releasing the he et from the
trunnions In the housing, using the long-handled emergey tools provided by
the manufacturer. Licensees who may be installing h draulic fluid. a nina knife unit should
be aware of the potential for contamination of the
This information notice requires no specific acti ihsnor written response. If
you have any questions about the information in notice, please contact
office.
the technical contact listed below, or the ap opriate NRC regional
Donald A Cool, Director
Divisi of Industrial and
Med al Nuclear Safety
Offt e of Nuclear Material
fety and Safeguards
Technical contact: Patricia . Holahan, NMSS
(301) 4 5-7847 Attachments:
1. List of Recently Iss d NMSS Information Notices
2. List of Recently Is ed NRC Information Notices
- See previous oncurrence _ No
OFC MA l AB c Tech Ed*l
NAME P Wbahan JMPlccone LWCamper EKraus
DATE / 414V95 03/27 95 03/30/95 03/10/95 OFt/ IM08 C OsS/;J& mlr.DIMNl_ EWBrach
D/IHNS
DACool
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N CCobs RLB a art rTlreby
ATE /i/919s9b3
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03/ /95 C a LUYLK LICIOF L REC O Cn0PY6V/W1G: I V. - ._
OFFICIAL RECORD COPY/G:\IMAB1979.PKH
a-_111 II
IN 95- March 1995 Licensees who possess a gamma knife unit should review their emerge y
procedures to ensure that they address situations In which the hy aulic
pressure is within normal operating range, but the bed fails to etract when
the timer reaches 0.0. In addition, operating staff should r lew emergency
procedures to include releasing the helmet from the trunnio in the housing, using the long-handled emergency tools provided by the man acturer.
Licensees who may be installing a gamma knife unit shoul be aware of the
potential for contamination of the hydraulic fluid.
This information notice requires no specific action or written response. If
you have any questions about the information in th s notice, please contact
the technical contact listed below, or the appro late NRC regional office.
Donald A. C 1, Director
Division o Industrial and
Medial Nuclear Safety
Office g Nuclear Material
Safey and Safeguards
Technical contact: Patricia K. olahan, NMSS
(301) 415-7 47 Attachments:
1. List of Recently Issued SS Information Notices
2. List of Recently Issued RC Information Notices
OFC IB kIL - - --EdI
Tech I
NAME -X ahan c e A er EKraus
DATE 03 95 /03/ /95 03_/0/95 03/10/95 OFC Y IMOB l SP lOGC r DD/IMNS l=7 DIN
D FCCombs RLBangart STreby EWBrach DACool
D E 03/ /95 03/ /95 03/ /95 03/ /95 03/ /95 C a COVER E a COVER & ENCLOSURE NaNO COPY
OFFICIAL RECORD COPY/G:\IMAB1979.PKH
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list | - Information Notice 1995-01, DOT Safety Advisory: High Pressure Aluminum Seamless and Aluminum Composite Hoop-Wrapped Cylinders (4 January 1995, Topic: Brachytherapy)
- Information Notice 1995-02, Problems With General Electric CR2940 Contact Blocks In Medium-Voltage Circuit Breakers (17 January 1995)
- Information Notice 1995-02, Problems With General Electric Cr2940 Contact Blocks In Medium-Voltage Circuit Breakers (17 January 1995)
- Information Notice 1995-02, Problems with General Electric CR2940 Contact Blocks in Medium-Voltage Circuit Breakers (17 January 1995)
- Information Notice 1995-03, Loss of Reactor Coolant Inventory and Potential Loss of Emergency Mitigation Functions While in a Shutdown Condition (18 January 1995, Topic: Packing leak, Water hammer)
- Information Notice 1995-04, Excessive Cooldown and Depressurization of the Reactor Coolant System Following Loss of Offsite Power (11 October 1996, Topic: Safe Shutdown, Shutdown Margin, Probabilistic Risk Assessment, Troxler Moisture Density Gauge)
- Information Notice 1995-05, Undervoltage Protection Relay Settings Out of Tolerance Due to Test Equipment Harmonics (20 January 1985)
- Information Notice 1995-06, Potential Blockage of Safety-Related Strainers by Material Brought Inside Containment (25 January 1995, Topic: Foreign Material Exclusion)
- Information Notice 1995-07, Radiopharmaceutical Vial Breakage During Preparation (27 January 1995)
- Information Notice 1995-08, Inaccurate Data Obtained with Clamp-On Ultrasonic Flow Measurement Instruments (30 January 1995)
- Information Notice 1995-08, Inaccurate Data Obtained With Clamp-On Ultrasonic Flow Measurement Instruments (30 January 1995)
- Information Notice 1995-09, Use of Inappropriate Guidelines and Criteria for Nuclear Piping and Pipe Support Evaluation and Design (31 January 1995, Topic: Operability Determination)
- Information Notice 1995-10, Potential for Loss of Automatic Engineered Safety Features Actuation (3 February 1995)
- Information Notice 1995-11, Failure of Condensate Piping Because of Erosion/Corrosion at Flow-Straightening Device (24 February 1995, Topic: Feedwater Heater)
- Information Notice 1995-12, Potentially Nonconforming Fasteners Supplied by A&G Engineering II, Inc (21 February 1995)
- Information Notice 1995-13, Potential for Data Collection Equipment to Affect Protection System Performance (24 February 1995)
- Information Notice 1995-14, Susceptibility of Containment Sump Recirculation Gate Valves to Pressure Locking (28 February 1995)
- Information Notice 1995-15, Inadequate Logic Testing of Safety-Related Circuits (7 March 1995)
- Information Notice 1995-16, Vibration Caused by Increased Recirculation Flow in a Boiling Water Reactor (9 March 1995)
- Information Notice 1995-17, Reactor Vessel Top Guide and Core Plate Cracking (10 March 1995, Topic: Safe Shutdown)
- Information Notice 1995-18, Potential Pressure-Locking of Safety-Related Power-Operated Gate Valves (15 March 1995)
- Information Notice 1995-19, Failure of Reactor Trip Breaker to Open Because of Cutoff Switch Material Lodged in the Trip Latch Mechanism (22 March 1995)
- Information Notice 1995-20, Failures in Rosemount Pressure Transmitters Due to Hydrogen Permeation Into Sensor Cell (22 March 1995)
- Information Notice 1995-21, Unexpected Degradation of Lead Storage Batteries (20 April 1995)
- Information Notice 1995-22, Hardened or Contaminated Lubricant Cause Metal-Clad Circuit Breaker Failures (21 April 1995)
- Information Notice 1995-23, Control Room Staffing Below Minimum Regulatory Requirements (24 April 1995)
- Information Notice 1995-24, Summary of Licensed Operator Requalification Inspection Program Findings (25 April 1995, Topic: Job Performance Measure, License Renewal)
- Information Notice 1995-25, Valve Failure During Patient Treatment with Gamma Stereotactic Radiosurgery Unit (11 May 1995, Topic: Overdose)
- Information Notice 1995-26, Defect in Safety-Related Pump Parts Due to Inadequate Treatment (31 May 1995)
- Information Notice 1995-27, NRC Review of Nuclear Energy Institute, Thermo-Lag 330-1 Combustibility Evaluation Methodology Plant Screening Guide. (31 May 1995, Topic: Safe Shutdown, Fire Barrier, Exemption Request, Fire Protection Program)
- Information Notice 1995-28, Emplacement of Support Pads for Spent Fuel Dry Storage Installations at Reactor Sites (5 June 1995, Topic: Safe Shutdown, Tornado Missile, Safe Shutdown Earthquake, Earthquake)
- Information Notice 1995-29, Oversight of Design and Fabrication Activities for Metal Components Used in Spent Fuel Dry Storage Systems (7 June 1995, Topic: Nondestructive Examination)
- Information Notice 1995-30, Susceptibility of Low-Pressure Coolant Injection Valves to Pressure Locking (3 August 1995, Topic: Hydrostatic, Power-Operated Valves)
- Information Notice 1995-31, Motor-Operated Valve Failure Caused by Stem Protector Pipe Interference (9 August 1995)
- Information Notice 1995-32, Thermo-Lag 330-1 Flame Spread Test Results (10 August 1995, Topic: Fire Barrier)
- Information Notice 1995-33, Switchgear Fire and Partial Loss of Offsite Power at Waterford Generating Station, Unit 3 (23 August 1995, Topic: Overspeed trip)
- Information Notice 1995-34, Air Actuator and Supply Air Regulator Problems in Copes-Vulcan Pressurizer Power-Operated Relief Valves (25 August 1995)
- Information Notice 1995-35, Degraded Ability of Steam Generators to Remove Decay Heat by Natural Circulation (28 August 1995)
- Information Notice 1995-36, Potential Problems with Post-Fire Emergency Lighting (29 August 1995, Topic: Safe Shutdown, Emergency Lighting, Exemption Request)
- Information Notice 1995-37, Inadequate Offsite Power System Voltages During Design-Basis Events (7 September 1995)
- Information Notice 1995-38, Degradation of Boraflex Neutron Absorber in Spent Fuel Storage Racks (8 September 1995)
- Information Notice 1995-39, Brachytherapy Incidents Involving Treatment Planning Errors (19 September 1995, Topic: Brachytherapy, Underdose)
- Information Notice 1995-40, Supplemental Information to Generic Letter 95-03, Circumferential Cracking of Steam Generator Tubes. (20 September 1995, Topic: Hydrostatic, Nondestructive Examination, Brachytherapy)
- Information Notice 1995-41, Degradation of Ventilation System Charcoal Resulting from Chemical Cleaning of Steam Generators (22 September 1995, Topic: Brachytherapy)
- Information Notice 1995-42, Commission Decision on Resolution of Generic Issue 23, Reactor Coolant Pump Seal Failure. (22 September 1995, Topic: Brachytherapy)
- Information Notice 1995-43, Failure of Bolt-Locking Device on Reactor Coolant Pump Turning Vane (28 September 1995, Topic: Brachytherapy)
- Information Notice 1995-44, Ensuring Compatible Use of Drive Cables Incorporating Industrial Nuclear Company Ball-Type Male Connectors (26 September 1995, Topic: Brachytherapy)
- Information Notice 1995-45, American Power Service Falsification of American Society for Nondestructive Testing Certificates (4 October 1995, Topic: Brachytherapy)
- Information Notice 1995-46, Unplanned, Undetected Release of Radioactivity from the Exhaust Ventilation System of a Boiling Water Reactor (6 October 1995, Topic: Brachytherapy)
- Information Notice 1995-47, Unexpected Opening of a Safety/Relief Valve & Complications Involving Suppression Pool Cooling Strainer Blockage (30 November 1995)
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