Information Notice 1995-50, Safety Defect in Gammamed 12I Bronchial Catheter Clamping Adapters

Safety Defect in Gammamed 12I Bronchial Catheter Clamping Adapters

ML031060156
Person / Time
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
Issue date:	10/30/1995
Revision:	0
From:	Cool D A NRC/NMSS/IMNS
To:
References
IN-95-050, NUDOCS 9510240405
Download: ML031060156 (12)

K) October 30, 1995NRC INFORMATION NOTICE 95-50:. SAFETY DEFECT IN GAMMAMED 12i BRONCHIALCATHETER CLAMPING ADAPTERS

Addressees

All High Dose Rate Afterloader (HDR) licensees.

Purpose

The U.S. Nuclear Regulatory Commission is issuing this information notice toalert addressees to the manufacturer's recommendation to discontinue use ofGammaMed 12i 1.8-millimeter(mm) bronchial catheter adapters. It is expectedthat recipients will review the information for applicability to theirfacilities and consider actions, as appropriate, to avoid similar problems.However, suggestions contained in this information notice are not new NRCrequirements; therefore, no specific action nor written response is required.DescriDtion of CircumstancesDuring a bronchial treatment, on November 16, 1994, using a GammaMed 12i HDR,the bronchial catheter pulled out of the catheter clamping adapter. Thisresulted in the clamping adapter clamping on the source wire, producing anabnormally high amount of friction during subsequent source movement. Ondetection of this interference to source movement, the device initiated anemergency retract, thus terminating the patient treatment. During thisemergency retract, the source became stuck in the clamping adapter,necessitating prompt emergency response, by the Radiation Oncology staff, toevacuate the patient from the high radiation area. The staff's prompt action,limited the excess whole body exposure to the patient to less than0.4 millisieverts (40 millirem). However, the HDR source and drive mechanismswere damaged and required replacement.On July 13, 1995, a similar incident occurred while vendor representativeswere performing the acceptance testing on a new GammaMed 12i. Again, thesource became stuck in the bronchial catheter clamping adapter after thecatheter had pulled loose from the adapter. In freeing the stuck source, thevendor's Radiation Safety Officer received an estimated extremity dose of26 centigray (rads). No patient was involved in this Incident.DiscussionAfter the first incident in November 1994, Frank Barker Associates, Inc.,provided all its GammaMed 12i customers with instructions for proper use ofthe GammaMed 12i, 1.8-mm bronchial catheter and associated clamping adapter.This notification (Attachment 1) was provided in the form of a BARKER+ TECH-TIP dated November 22, 1994.9510240405 iPP& qPS&o 9S got Y4 IN 95-50October 30, 1995 After the second incident in July 1995, Frank Barker Associates, Inc., issuedtwo more notifications, to its customers on the use of the 1.8-mm bronchialcatheter clamping adapters, Product Number 931-012. The first of these(Attachment 2) was another BARKER+ TECH-TIP, dated July 18, 1995, whichadvised customers to avoid the Wend testm mode of operation with the white1.8-mm bronchial catheter, as this mode will stretch the catheter and possiblypush the catheter out of the clamping adapter. This TECH-TIP goes on todescribe the sticking of the source, in the clamping adapter, should thecatheter be pushed out of the adapter.Frank Barker Associates, Inc. also held discussions with the NRC, regardingradiation safety issues associated with the failure of the GammaMed 12idevices to retract the source into its shielded safe after a bronchialcatheter has been pulled out of the clamping adapter. They subsequently senta letter dated August 18, 1995, (Attachment 3) to all 12i users, advising themto discontinue use of these adapters. The letter further advised the usersthat new clamping adapters were in production and would be provided to them inOctober 1995.NRC is concerned about the possibility of ether patients or licensee staffreceiving excessive exposures to radiation if an HDR source fails to retract.Because of this documented defect in the GammaMed 12i bronchial clampingadapters, all affected licensees are encouraged to follow the recommendationsof the device vendor, as contained in its letter of August 18, 1995. Anylicensee using this adapter to complete a course of treatment started beforethe vendor's notification should exercise extreme caution.This information notice requires no specific action nor written response. Ifyou have any questions about the information in this notice, please contactthe technical contact listed below or the appropriate regional office.Donald A. Cool, DirectorDivision of Industrial'andMedical Nuclear SafetyOffice of Nuclear Material Safetyand Safeguards

Technical Contact:

Robert L. Ayres, NMSS

Attachments:

(301) 415-5746 771. BARKER+ TECH-TIP, dated November 22, 19942. BARKER+ TECH-TIP, dated July 18, 19953. BARKER+ Letter, dated August 18, 19954. List of Recently Issued NMSS Information Notices5. List of Recently Issued NRC Information Notices DOC NAME: 95-50.IN* See Previous ConcurrenceOFC IMABl1 IMAB lEIMAB lC; IMOB I ClNAME *RAyres *JMPICCONE *LWCamper *RBaer *GPangbunDATE 10/16/95 1 9/19/95 9/19/95 9/20/95 9/20/95..AFf I TarhFd I I r I- I DDIIMNS I I D/IMNS Ivanw An.,. A___ _ __ _ __ _ __ _ _ ___ .________________________,_ _,_________________________..KNAE *EKrause *STreby *FCCombs *DACool9/21/95 10/02/95 10/12/95 10/17/95 _

INSeptember , 1995 /After the second incident in July 1995, Frank Barker Associates ,'nc., issuedtwo more notifications, to its customers on the use of the 1.8Am bronchialcatheter clamping adapters, Product Number 931-012. The first of these(Attachment 2) was another BARKER+ TECH-TIP, dated July 18, A995, whichadvised customers to avoid the "end test" mode of operati with the white1.8-mm bronchial catheter, as this mode will stretch the/catheter and possiblypush the catheter out of the clamping adapter. This TOtH-TIP goes on todescribe the sticking of the source, in the clamping adapter, should thecatheter be pushed out of the adapter. /Frank Barker Associates, Inc. also held discussiW< with the NRC, regardingradiation safety issues associated with the fal ure of the GammaMed 12idevices to retract the source into its shield d safe after a bronchialcatheter has been pulled out of the clampin adapter. They subsequently senta letter dated August 18, 1995, (Attachmen 3) to all 12i users, advising themto discontinue use of these adapters. The letter further advised the usersthat new clamping adapters were in prodution and would be provided to them inOctober 1995. /NRC is concerned about the possibil,4y of ether patients or licensee staffreceiving excessive exposures to diation if an HDR source fails to retract.Because of this documented defe in the GammaMed 12i bronchial clampingadapters, all affected license s are encouraged to follow the recommendationsof the device vendor, as con ned in its letter of August 18, 1995. Anylicensee using this adapter o complete a course of treatment started beforethe vendor's notification ould exercise extreme caution.This information notice requires no specific action nor written response. Ifyou have any question about the information in this notice, please contactthe technical contac listed below or the appropriate regional office.Donald A. Cool, DirectorDivision of Industrial andMedical Nuclear SafetyOffice of Nuclear Material Safetyand SafeguardsTechnical ontact: Robert L. Ayres, NMSS(301) 415-5746Attach nts:1. BAKER+ TECH-TIP, dated November 22, 19942. ARKER+ TECH-TIP, dated July 18, 19953. BARKER+ Letter, dated August 18, 19954 List of Recently Issued NMSS Information Notices*. List of Recently Issued NRC Information Notices G:\Gammamed.InSee Previous ConcurrenceOF IMAB I Ofl IMAB I E IMB IC SSSS l MO IENAME RAyres ; j._4 *JMPICCONE *LWCamper *RBaer *GPangbunDATE __ t Is//95 1 9/19/95 9/19/95 9/20/95 _ 9/20/95-A I I Tnrr I TehFi I I OMC I I DD/IMNS I I QiJ4Nb.'o'I-. -.-.- I --- * -. iNAME *EKrause *STreby *FCCombsDATE 9/21/95 10/02/95 10/12/95 tofe /t /Its, INSeptember , 1995 After the second incident in July 1995, Frank Barker Associates, Inc., issuedtwo more notifications, to its customers on the use of the 1.8-mm bronchialcatheter clamping adapters, Product Number 931-012. The first of these(Attachment 2) was another BARKER+ TECH-TIP, dated July 18, 1995, whichadvised customers to avoid the *end test' mode of operation with the white1.8-mm bronchial catheter, as this mode wUji stretch the catheter and possiblypush the catheter out of the clamping adapter. This TECH-TIP goes on todescribe the sticking of the source, in the clamping adapter, should thecatheter be pushed out of the adapter.Frank Barker Associates, Inc. also held discussions with the NRC, regardingradiation safety issues associated with the failure of the GammaMed 12idevices to retract the source into its shielded safe after a bronchialcatheter has been pulled out of the clamping adapter. They subsequently senta letter dated August 18, 1995, (Attachment 3) to all 12i users, advising themto discontinue use of these adapters. The letter further advised the usersthat new clamping adapters were in production and would be provided to them inOctober 1995.NRC is concerned about the possibility of ether patients or licensee staffreceiving excessive exposures to radiation if an HDR source fails to retract.Because of this documented defect in the GammaMed 12i bronchial clampingadapters, all affected licensees are encouraged to follow the recommendationsof the device vendor, as contained in its letter of August 18, 1995. Anylicensee using this adapter to complete a course of treatment started beforethe vendor's notification should exercise extreme caution.Related Generic Communications:This information notice requires no specific action nor written response. Ifyou have any questions about the information in this notice, please contactthe technical contact listed below or the appropriate regional office.Donald A. Cool, DirectorDivision of Industrial andMedical Nuclear SafetyOffice of Nuclear Material Safetyand Safeguards

Technical Contact:

Robert L. Ayres, NMSS(301) 415-5746

Attachments:

1. BARKER+ TECH-TIP, dated November 22, 19942. BARKER+ TECH-TIP, dated July 18, 19953. BARKER+ Letter, dated August 18, 19954. List of Recently Issued NMSS Information Notices5. List of Recently Issued NRC Information Notices G:\Gammamed.In* See Previous ConcurrencelOCIMAB I E IfMAB SS FE IMABlCIOFC LIMABEI r[Z-IK -iIK 3j§EZ~NAME RAyresz .< *JMPICCONE *LWCamper *RBaer *GPangbunDATE I .,oA/oi/95 j9/19/95 __ 9/19/95 9/20/95 l 9/20/95I- ----A .I InAr I TcrhFA I I Or/c I I WINS \II I D/IMNSNAME *EKrause *STreby FCZb I I DACoolDATE 9/21/95 10/02/95 \O/\"Y 11> / /

September , 1995 Following the second Incident in July 1995, Frank Barker Associates, Inc.,issued two more notifications to their customers on the use of the 1.8mmbronchial catheter clamping adapters, Product Number 931-012. The first ofthese (Attachment 2) was another BARKER+ TECH-TIP dated July 18, 1995,advising their customers to avoid the 'end test' mode of operation with thewhite 1.8mm bronchial catheter as this mode will stretch the catheter andpossibly push the catheter out of the clamping adapter. This TECH-TIP goes onto describe the sticking of the source in the clamping adapter should thecatheter be pushed out of the adapter.After discussions with the NRC, related to radiation safety issues associatedwith the failure of the GammaMed 12i devices to retract the source into itsshielded safe after a bronchial catheter has been pulled out of the clampingadapter, Frank Barker Associates, Inc., sent a letter dated August 18, 1995,(Attachment 3) to all 121 users advising them to discontinue use of theseadapters. The letter further advised their users that new clamping adapterswere in production and would be provided to them in October 1995.The NRC is concerned about the potential for excessive exposures to radiationby either patients, or licensee staff, in the event of the failure of an HDRsource to retract, due to this documented defect in the GammaMed 121 bronchialclamping adapters. All affected licensees are encouraged to follow therecommendations of the device vendor, as contained in their letter ofAugust 18, 1995. Extreme caution should be exercised by any licensee usingthis adapter to complete a course of treatment that was started prior to thevendor's notification.Related Generic Communications:This information notice requires no specific action or written response. Ifyou have any questions about the information in this notice, please contactthe technical contact listed below or the appropriate regional office.Donald A. Cool, DirectorDivision of Industrial andMedical Nuclear SafetyOffice of Nuclear Material Safetyand Safeguards

Technical Contact:

Robert L. Ayres, NMSS(301) 415-5746

Attachments:

1. BARKER+ TECH-TIP, dated November 22, 19942. BARKER+ TECH-TIP, dated July 18, 19953. BARKER+ Letter, dated August 18, 19954. List of Recently Issued NMSS Information Notices5. List of Recently Issued NRC Information Notices G:\Gammamed.InOFCOFC IMAB OI I ENAME RAyresmA4 _S__CNE_ _Wer = __ __ aer GDATE 9/1q/95 9/1Q/95 J,46 OWNq_ 1 / X___ __a___ /_5fiOFm I TechEd I I It; LVW "'It I DDn1i NIM / I D/IMNS INAME EKrause 1 T DACoolDATE / IJ f r / _t / __ __/_ / /

09/22i1995 1'1:29INRC IMNS DIVISION2025175133TEL :301-504-S369FETZEP-MUS, IMC.PAG 0'1SPD 20O9517:17 No .010 P.04/04INuSptember , 1995 second incident In Jull 1965, Frank Barkar Ascocites, tissued two more notification to custwer*,Pn the use of the .bronchial catheter claping sxapters, Product Nd~cr 911-01t. The frt f(Attachunt Z) wis another SARKEj+ TECH TIdatG4 July 18 , I95; wstms to avoid the e snd teZt d of operation with thewhite 1. bronchial catheterS thIs mode stretch the catheter anda ssbS sh the catheter ourof the clamping dapter. This TECH-TIP oes ano des ths sticking of the %ource, th c&aping adaptev hoIld thcatheter be pushed out of the adapter.1with H NRCve radiation safety IWMs associatedlure of the G ed 121 devices to retract the aource into itsineAftar nchil ecatheter has been pulled ou-LgL9I'e t i 'spurcqu Vw.I rL, t,__ -.clampng adapters. A-l .(roctad "1censee I re enco Ea tvncundations of the device vendor, as containad IAugust 18. 1995. -6tk c..c l&uAiosl'i nethis adapter to complete a ceurso of treatment tht was I cvendor's notif1catioi, V"A Akb't" # C (:: i.Reltatd Gentric EJMOUflleAtiQi!This tnformation notice requires no specific actt1 6 PWritten response. Ifyou have any questions about the information in thirnotie pitase contactthe technical contact listed below or the appropriate regiunaJ OffiCe.4,,Donald A. Cools DirectorDivision of Industrial 3WMedical Nuclear SafetyOffice of Nulear Material Safetyand SafegutrdsRobert L. Ayres, W4SS(301) 415-5740

Attachments:

1. -AMVP4-2. BAKER+3. 8ARXER+4. List of..- ^ .TECH-TIP, dated November Us, 1994TECN-TIP, dated July 18. 19SLetter, daid August 18, 1495Recently Issued NSS Infofmation Notices1I01% mL1,4 PT Itf t 5m md.TnOPC MIIu ISWarFvv w. w vHAKE I R~yrs4______/ _V ..LtrA. Ifur Inniimms IWIIFS I---UPG ERULNU I _______________ --N I EIre M by F~combs DAC001iqaLI-abL/.L -=L'4)I IN 95-50October 30, 1995 After the second incident in July 1995,-Frank Barker Associates, Inc., issuedtwo more notifications, to its customers on the use of the 1.8-mm bronchialcatheter clamping adapters, Product Number 931-012. The first of these(Attachment 2) was another BARKER+ TECH-TIP, dated July 18, 1995, whichadvised customers to avoid the lend test" mode of operation with the white1.8-mm bronchial catheter, as this mode will stretch the catheter and possiblypush the catheter out of the clamping adapter. This TECH-TIP goes on todescribe the sticking of the source, in the clamping adapter, should thecatheter be pushed out of the adapter.Frank Barker Associates, Inc. also held discussions with the NRC, regardingradiation safety issues associated with the failure of the GammaMed 121devices to retract the source into its shielded safe after a bronchialcatheter has been pulled out of the clamping adapter. They subsequently senta letter dated August 18, 1995, (Attachment 3) to all 12i users, advising themto discontinue use of these adapters. The letter further advised the usersthat new clamping adapters were in production and would be provided to them inOctober 1995.NRC is concerned about the possibility of ether patients or licensee staffreceiving excessive exposures to radiation if an HDR source fails to retract.Because of this documented defect in the GammaMed 12i bronchial clampingadapters, all affected licensees are encouraged to follow the recommendationsof the device vendor, as contained in its letter of August 18, 1995. Anylicensee using this adapter to complete a course of treatment started beforethe vendor's notification should exercise extreme caution.This information notice requires no specific action nor written response. Ifyou have any questions about the information in this notice, please contactthe technical contact listed below or the appropriate regional office.2,&/ 'IDonald A. Cool, DirectorDivision of Industrial andMedical Nuclear SafetyOffice of Nuclear Material Safetyand SafeguardsTechnical contact: Robert L. Ayres, NMSS(301) 415-5746

Attachments:

1. BARKER+ TECH-TIP, dated November 22, 19942. BARKER+ TECH-TIP, dated July 18, 19953. BARKER+ Letter, dated August 18, 19954. List of Recently Issued NMSS Information Notices5. List of Recently Issued NRC Information Notices ar.Attachment 1IN 95-50October 30, 1995 B A R K E R + T EC H -T I PDATE: November 22. 1994TO: All GAMMAMED 12i UsersFROM: Garry Nixon -U.S. GAMMAMED Service ManagerRE: GAMMAMED 12i Bronchial Catheters and Clamping AdaptersFor the safest operation of your GAMMAMED 12i HDR unit please follow the followingprocedures when using the white 1.8mm bronchial catheter with its associated dampingadapter.The proper procedure before inserting the damping adapter into the treatment head is:1) depre" the end of the dcamping adapter,2) insert the white 1.8mm catheter Into the damping adapter as far as It will go,3) release the end of the damping adapter,4) Zull on the end of the damping adapter while holding it as illustratfd below to iocke itfirmly on the catheter,6) now inset the damping adapter Into the treatment head.Old Stcalamping Adapterhold pull to lockhaceUew StyleCamping Adapterhold_ pull to loclchemeIn order to avoid the catheter being pulled from the damping adapter In the case of thepatient moving, insure that slack exists in the catheter between the patent and the HORtreatment head. This will be facilitated by positioning the tre3anent unit as near ac Ispossible to the patient.If you have any questions please contact me at our toll-free number 1-800-2-BARKER a --Attachment 2IN 95-50October 30, 1995 BARKER+ TECH-TIPDATE: July 18, 1995TO: Al Gammmed 12i UsersFROM: Garry Nixon -U.S. Iammned Service ManagerRE: Bronclal catheters to be used p in indexer chamncls 20 -24I would like to remind all Gtmamed 12i Users that whaeever using the white 1.8mmbronchial cathctcr, that this catheter will stretch if a duznry wire 'end test' is performed.This will most likely cause the console eror message "Probe too long in channe 1".There is also the distinct possibility that in the process of the dummy wire pushingagainst the end of the catheter, it will push the catheter almost completely out of the meulclamping adapte which connects the catheter to the 12i's indexer channeL It is possiblethat the source could complet.ly pubh the cathctcr out of the clamping adaptcr whichwould result in the clanping adapter no longer clamping on the catheter but ratherclamping on the source wire! During the next movement of the source wire, theabnormally high amount of frictin (between the cliapiig auapter and the source wire)will be detected and an Emergency Ret will be initiated, thus terminating thetreatment. lf; during this Emergency Reawt, the wire becomes saLk in Lhe clump, it maynot be possible to completely retact the source capsule into it's "safe' position in thedepleted uranium shielding. This obviously would necessitate intervention within thenmument room by the Radiation Oncology staff conducting the treatment, to evacuate thepatent; and by a BARKER+ Servce Egineer to retrieve the source into the shielding ora shipping container.In o to avoid this scrio, it iiimp at s adapter b used in indexerchannels 1-19. ThcI c ubwwels ae pvogmramcd to do an end t1st with c dummybefore extending the source wire. Chnels 20-24 do not do this end test and weredesigned this way to be used with this catheter/clamping adapter applicator.if you have any questions please contact me at ow toll-free number 1-800-2-BARKER-

& -Attachment 3IN 95-50October 30, 1995 BARKER+Sales and Marketing Division33 JacktsonvlltG Road, Bldg.#1Towaco, NJ 07082Phone: (800) 222-7637FAX.: (201) 335-1225Date: August 18, 1995To:ATTN:'From:Jeff SticklerNumber of Pages including this one: 1Frank Rarker Associates. Inc. hereby advises all 12i Users that are presently usinq the12i damping adapter, product number 931-012, either old style or new style, to discontinue use ofthese adapters. However. if ynt Art presently treating a patient using these adapters. we wouldadvise that you finish treatments: 1) using the old style adapter if you have one and or; 2)following the Tech Tops which we supplied to hp nprtain that the adapter is in the locked position.This docision was made after discussion with the NR(^ and the manufacturer.ITSiGAMAMED has a new clamping adapter in production which will become available inOctor 1096. At tfat time we will replace any of these specific adapters free of charge tn theUsers.If you have any questions regarding this matter please contact Jeff Stickier at the abovetoll-free number and exton5o;n. 608 ot your convenience.Respectfully,jusfley C. SticgerOirector Customer SupportExtension 608 a .Attachment 4IN 95-50October 30, 1995 LIST OF RECENTLY ISSUEDNMSS INFORMATION NOTICESInformation Date ofNotice No. Subject Issuance Issued to95-4495-3995-2995-2895-2594-64,Supp. 195-0795-01Ensuring Combatible Use ofDrive Cables IncorporatingIndustrial Nuclear CompanyBall-type Male ConectorsBrachytherapy IncidentsInvolving TreatmentPlanning ErrorsOversight of Design andand Fabrication Activitiesfor Metal Components Usedin Spent Fuel Dry StorageSystemsEmplacement of SupportPads for Spent Fuel DryStorage Installations atReactor SitesValve Failure duringPatient Treatment withGamma StereotacticRadiosurgery UnitReactivity Insertion Trans-ient and Accident Limitsfor High Burnup FuelRadiopharmaceutical VialBreakage during PreparationDOT Safety Advisory:High Pressure AluminumSeamless and AluminumComposite Hoop-WrappedCylinders09/26/9509/19/9506/07/9506/05/9505/11/9504/06/9501/27/9501/04/95All Radiography Licensees.All U.S. Nuclear RegulatoryCommission MedicalLicensees.All holders of OLs or CPsfor nuclear power reactors.Independent spent fuelstorage installationdesigners and fabricators.All holders of OLs or CPsfor nuclear power reactorsAll U.S. Nuclear RegulatoryCommission MedicalLicensees.All holders of OLs or CPsfor Nuclear Power Reactorsand all fuel fabricationlicensees.All U.S. Nuclear RegulatoryCommission medical licenseesauthorized to use byproductmaterial for diagnosticprocedures.All U.S. Nuclear RegulatoryCommission licensee K-,V 6 .Attachment 5IN 95-50October 30, 1995Page I of 1LIST OF RECENTLY ISSUEDNRC INFORMATION NOTICESInformation Date ofNotice No. Subject Issuance Issued to95-4995-4895-4795-46Seismic Adequacy ofThermo-Lag Panel sResults of Shift StaffingStudyUnexpected Opening of aSafety/Relief Valve andComplications InvolvingSuppression Pool CoolingStrainer BlockageUnplanned, UndetectedRelease of Radioactivityfrom the Exhaust VentilationSystem of a Boiling WaterReactorPotentially NonconformingFasteners Supplied byA&G Engineering II, Inc.American Power ServiceFalsification of AmericanSociety for NondestructiveTesting (ASNT) CertificatesEnsuring Compatible Use ofDrive Cables IncorporatingIndustrial Nuclear CompanyBall-Type Male ConnectorsFailure of the Bolt-LockingDevice on the ReactorCoolant Pump Turning Vane10/27/9510/10/9510/04/9510/06/9510/05/9510/04/9509/26/9509/28/95All holders of OLs or CPsfor nuclear power reactors.All holders of OLs or CPsfor nuclear power reactors.All holders of OLs or CPsfor nuclear power reactors.All holders of OLs or CPsfor nuclear power reactors.All holders of OLs or CPsfor nuclear power reactors.All holders of OLs or CPsfor nuclear power reactors.All Radiography Licensees.All holders of OLs or CPsfor nuclear power reactorsdesigned by WestinghouseElectric Corporation (W).95-12,Supp. 195-4595-4495-4395-42Commission Decision on theResolution of GenericIssue 23, NReactor CoolantPump Seal Failure'09/22/95All holders of OLs or CPsfor nuclear power reactors.OL -Operating LicenseCP -Construction Permit