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
From:	Cool D NRC/NMSS/IMNS
To:
References
IN-95-050, NUDOCS 9510240405
Download: ML031060156 (12)

K)

UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS

WASHINGTON, D.C. 20555-0001 October 30, 1995 NRC INFORMATION NOTICE 95-50:. SAFETY DEFECT IN GAMMAMED 12i BRONCHIAL

CATHETER CLAMPING ADAPTERS

Addressees

All High Dose Rate Afterloader (HDR) licensees.

Purpose

The U.S. Nuclear Regulatory Commission is issuing this information notice to

alert addressees to the manufacturer's recommendation to discontinue use of

GammaMed 12i 1.8-millimeter(mm) bronchial catheter adapters. It is expected

that recipients will review the information for applicability to their

facilities and consider actions, as appropriate, to avoid similar problems.

However, suggestions contained in this information notice are not new NRC

requirements; therefore, no specific action nor written response is required.

DescriDtion of Circumstances

During a bronchial treatment, on November 16, 1994, using a GammaMed 12i HDR,

the bronchial catheter pulled out of the catheter clamping adapter. This

resulted in the clamping adapter clamping on the source wire, producing an

abnormally high amount of friction during subsequent source movement. On

detection of this interference to source movement, the device initiated an

emergency retract, thus terminating the patient treatment. During this

emergency retract, the source became stuck in the clamping adapter, necessitating prompt emergency response, by the Radiation Oncology staff, to

evacuate the patient from the high radiation area. The staff's prompt action, limited the excess whole body exposure to the patient to less than

0.4 millisieverts (40 millirem). However, the HDR source and drive mechanisms

were damaged and required replacement.

On July 13, 1995, a similar incident occurred while vendor representatives

were performing the acceptance testing on a new GammaMed 12i. Again, the

source became stuck in the bronchial catheter clamping adapter after the

catheter had pulled loose from the adapter. In freeing the stuck source, the

vendor's Radiation Safety Officer received an estimated extremity dose of

26 centigray (rads). No patient was involved in this Incident.

Discussion

After the first incident in November 1994, Frank Barker Associates, Inc.,

provided all its GammaMed 12i customers with instructions for proper use of

the 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.

9 510240405 i

PP& qPS&o 9S Y4 got

IN 95-50

October 30, 1995 After the second incident in July 1995, Frank Barker Associates, Inc., issued

two more notifications, to its customers on the use of the 1.8-mm bronchial

catheter clamping adapters, Product Number 931-012. The first of these

(Attachment 2) was another BARKER+ TECH-TIP, dated July 18, 1995, which

advised customers to avoid the Wend testm mode of operation with the white

1.8-mm bronchial catheter, as this mode will stretch the catheter and possibly

push the catheter out of the clamping adapter. This TECH-TIP goes on to

describe the sticking of the source, in the clamping adapter, should the

catheter be pushed out of the adapter.

Frank Barker Associates, Inc. also held discussions with the NRC, regarding

radiation safety issues associated with the failure of the GammaMed 12i

devices to retract the source into its shielded safe after a bronchial

catheter has been pulled out of the clamping adapter. They subsequently sent

a letter dated August 18, 1995, (Attachment 3) to all 12i users, advising them

to discontinue use of these adapters. The letter further advised the users

that new clamping adapters were in production and would be provided to them in

October 1995.

NRC is concerned about the possibility of ether patients or licensee staff

receiving excessive exposures to radiation if an HDR source fails to retract.

Because of this documented defect in the GammaMed 12i bronchial clamping

adapters, all affected licensees are encouraged to follow the recommendations

of the device vendor, as contained in its letter of August 18, 1995. Any

licensee using this adapter to complete a course of treatment started before

the vendor's notification should exercise extreme caution.

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 regional office.

Donald A. Cool, Director

Division of Industrial'and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Robert L. Ayres, NMSS

Attachments: (301) 415-5746 77

1. BARKER+ TECH-TIP, dated November 22, 1994

2. BARKER+ TECH-TIP, dated July 18, 1995

3. BARKER+ Letter, dated August 18, 1995

4. List of Recently Issued NMSS Information Notices

5. List of Recently Issued NRC Information Notices DOC NAME: 95-50.IN

• See Previous Concurrence

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DATE 10/16/95 1 9/19/95 9/19/95 9/20/95 9/20/95

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September , 1995 /

After the second incident in July 1995, Frank Barker Associates ,'nc., issued

two more notifications, to its customers on the use of the 1.8Am bronchial

catheter clamping adapters, Product Number 931-012. The first of these

(Attachment 2) was another BARKER+ TECH-TIP, dated July 18, A995, which

advised customers to avoid the "end test" mode of operati with the white

1.8-mm bronchial catheter, as this mode will stretch the/catheter and possibly

push the catheter out of the clamping adapter. This TOtH-TIP goes on to

describe the sticking of the source, in the clamping adapter, should the

catheter be pushed out of the adapter. /

Frank Barker Associates, Inc. also held discussiW< with the NRC, regarding

radiation safety issues associated with the fal ure of the GammaMed 12i

devices to retract the source into its shield d safe after a bronchial

catheter has been pulled out of the clampin adapter. They subsequently sent

a letter dated August 18, 1995, (Attachmen 3) to all 12i users, advising them

to discontinue use of these adapters. The letter further advised the users

that new clamping adapters were in prodution and would be provided to them in

October 1995. /

NRC is concerned about the possibil, 4y of ether patients or licensee staff

receiving excessive exposures to diation if an HDR source fails to retract.

Because of this documented defe in the GammaMed 12i bronchial clamping

adapters, all affected license s are encouraged to follow the recommendations

of the device vendor, as con ned in its letter of August 18, 1995. Any

licensee using this adapter o complete a course of treatment started before

the vendor's notification ould exercise extreme caution.

This information notice requires no specific action nor written response. If

you have any question about the information in this notice, please contact

the technical contac listed below or the appropriate regional office.

Donald A. Cool, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical ontact: Robert L. Ayres, NMSS

(301) 415-5746 Attach nts:

1. BAKER+ TECH-TIP, dated November 22, 1994

2. ARKER+ TECH-TIP, dated July 18, 1995

3. BARKER+ Letter, dated August 18, 1995

4 List of Recently Issued NMSS Information Notices

• . List of Recently Issued NRC Information Notices G:\Gammamed.In

See Previous Concurrence

OF IMAB I Ofl IMAB I E IMB IC SSSS l MO IE

NAME RAyres  ; j._4 *JMPICCONE *LWCamper *RBaer *GPangbun

DATE __ t

Is//95 1 9/19/95 9/19/95 A I

9/20/95 _ 9/20/95 I T

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nrr I -.-.- TehFi II I OMC I I DD/IMNS I I QiJ4Nb.'o'I i

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NAME *EKrause *STreby *FCCombs

DATE 9/21/95 10/02/95 10/12/95 tofe

/t /Its,

IN

September , 1995 After the second incident in July 1995, Frank Barker Associates, Inc., issued

two more notifications, to its customers on the use of the 1.8-mm bronchial

catheter clamping adapters, Product Number 931-012. The first of these

(Attachment 2) was another BARKER+ TECH-TIP, dated July 18, 1995, which

advised customers to avoid the *end test' mode of operation with the white

1.8-mm bronchial catheter, as this mode wUji stretch the catheter and possibly

push the catheter out of the clamping adapter. This TECH-TIP goes on to

describe the sticking of the source, in the clamping adapter, should the

catheter be pushed out of the adapter.

Frank Barker Associates, Inc. also held discussions with the NRC, regarding

radiation safety issues associated with the failure of the GammaMed 12i

devices to retract the source into its shielded safe after a bronchial

catheter has been pulled out of the clamping adapter. They subsequently sent

a letter dated August 18, 1995, (Attachment 3) to all 12i users, advising them

to discontinue use of these adapters. The letter further advised the users

that new clamping adapters were in production and would be provided to them in

October 1995.

NRC is concerned about the possibility of ether patients or licensee staff

receiving excessive exposures to radiation if an HDR source fails to retract.

Because of this documented defect in the GammaMed 12i bronchial clamping

adapters, all affected licensees are encouraged to follow the recommendations

of the device vendor, as contained in its letter of August 18, 1995. Any

licensee using this adapter to complete a course of treatment started before

the vendor's notification should exercise extreme caution.

Related Generic Communications:

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 regional office.

Donald A. Cool, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Robert L. Ayres, NMSS

(301) 415-5746 Attachments:

1. BARKER+ TECH-TIP, dated November 22, 1994

2. BARKER+ TECH-TIP, dated July 18, 1995

3. BARKER+ Letter, dated August 18, 1995 IOFC

NAME

DATE

4. List of Recently Issued NMSS Information Notices

5. List of Recently Issued NRC Information Notices G:\Gammamed.In

• See Previous Concurrence

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NAME *EKrause *STreby FCZb I I DACool

DATE 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 1.8mm

bronchial catheter clamping adapters, Product Number 931-012. The first of

these (Attachment 2) was another BARKER+ TECH-TIP dated July 18, 1995, advising their customers to avoid the 'end test' mode of operation with the

white 1.8mm bronchial catheter as this mode will stretch the catheter and

possibly push the catheter out of the clamping adapter. This TECH-TIP goes on

to describe the sticking of the source in the clamping adapter should the

catheter be pushed out of the adapter.

After discussions with the NRC, related to radiation safety issues associated

with the failure of the GammaMed 12i devices to retract the source into its

shielded safe after a bronchial catheter has been pulled out of the clamping

adapter, Frank Barker Associates, Inc., sent a letter dated August 18, 1995, (Attachment 3) to all 121 users advising them to discontinue use of these

adapters. The letter further advised their users that new clamping adapters

were in production and would be provided to them in October 1995.

The NRC is concerned about the potential for excessive exposures to radiation

by either patients, or licensee staff, in the event of the failure of an HDR

source to retract, due to this documented defect in the GammaMed 121 bronchial

clamping adapters. All affected licensees are encouraged to follow the

recommendations of the device vendor, as contained in their letter of

August 18, 1995. Extreme caution should be exercised by any licensee using

this adapter to complete a course of treatment that was started prior to the

vendor's notification.

Related Generic Communications:

This information notice requires no specific action or written response. If

you have any questions about the information in this notice, please contact

the technical contact listed below or the appropriate regional office.

Donald A. Cool, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Robert L. Ayres, NMSS

(301) 415-5746 Attachments:

1. BARKER+ TECH-TIP, dated November 22, 1994

2. BARKER+ TECH-TIP, dated July 18, 1995

3. BARKER+ Letter, dated August 18, 1995

4. List of Recently Issued NMSS Information Notices

5. List of Recently Issued NRC Information Notices G:\Gammamed.In

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NAME RAyresmA4 =

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DATE 9/1q/95 9/1Q/95 J,46 OWNq_ 1 X___ __a___ / /_5fi

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2025175133 FETZEP-MUS, IMC. PAG 0'1

09/22i1995 1'1:29 SPD 20O95 17:17 No .010 P.04/0 4 TEL : 301-504-S369

INRC IMNS DIVISION

IN

uSptember , 1995 second incident In Jull 1965, Frank Barkar use Ascocites, t

issued two more notification to custwer*,Pn the 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 snd d of operation with the

e teZt

white 1. bronchial catheterS thIs mode stretch the catheter and

a ssbS sh the catheter ourof the clamping dapter. This TECH-TIP oes an

o des ths sticking of the %ource, th c&aping adaptev hoIld th

catheter be pushed out of the adapter.

1with H NRCve radiation safety IWMs associated

lure of the G ed 121 devices to retract the aource into its

ineAftar nchilecatheter has been pulled ou-LgL9I'e t i'

spurcqu Vw.I

clampng adapters. A-l .(roctad

rL, t,__

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re I enco

"1censee Ea

t

vncundations of the device vendor, as containad I

August 18. 1995. -6tk c..c ne

l&uAiosl'i

was cI

this adapter to complete a ceurso of treatment tht

vendor's notif1catioi, V"A Akb't"

1. C (:: i.

Reltatd Gentric EJMOUflleAtiQi!

4,,

This tnformation notice requires no specific actt1thirnotie 6 PWritten response. If

you have any questions about the information in pitase contact

the technical contact listed below or the appropriate regiunaJ OffiCe.

Donald A.Cools Director

Division of Industrial 3W

Medical Nuclear Safety

Office of Nulear Material Safety

and Safegutrds

Robert L. Ayres, W4SS

(301) 415-5740

Attachments:

1. -AMVP4- TECH-TIP, dated November Us, 1994

2. BAKER+ TECN-TIP, dated July 18. 19S

3. 8ARXER+ Letter, daid August 18, 1495

4. List of Recently Issued NSS Infofmation Notices

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IN 95-50

October 30, 1995 After the second incident in July 1995,-Frank Barker Associates, Inc., issued

two more notifications, to its customers on the use of the 1.8-mm bronchial

catheter clamping adapters, Product Number 931-012. The first of these

(Attachment 2) was another BARKER+ TECH-TIP, dated July 18, 1995, which

advised customers to avoid the lend test" mode of operation with the white

1.8-mm bronchial catheter, as this mode will stretch the catheter and possibly

push the catheter out of the clamping adapter. This TECH-TIP goes on to

describe the sticking of the source, in the clamping adapter, should the

catheter be pushed out of the adapter.

Frank Barker Associates, Inc. also held discussions with the NRC, regarding

radiation safety issues associated with the failure of the GammaMed 121 devices to retract the source into its shielded safe after a bronchial

catheter has been pulled out of the clamping adapter. They subsequently sent

a letter dated August 18, 1995, (Attachment 3) to all 12i users, advising them

to discontinue use of these adapters. The letter further advised the users

that new clamping adapters were in production and would be provided to them in

October 1995.

NRC is concerned about the possibility of ether patients or licensee staff

receiving excessive exposures to radiation if an HDR source fails to retract.

Because of this documented defect in the GammaMed 12i bronchial clamping

adapters, all affected licensees are encouraged to follow the recommendations

of the device vendor, as contained in its letter of August 18, 1995. Any

licensee using this adapter to complete a course of treatment started before

the vendor's notification should exercise extreme caution.

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 regional office.

2,&/ 'I

Donald A. Cool, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical contact: Robert L. Ayres, NMSS

(301) 415-5746 Attachments:

1. BARKER+ TECH-TIP, dated November 22, 1994

2. BARKER+ TECH-TIP, dated July 18, 1995

3. BARKER+ Letter, dated August 18, 1995

4. List of Recently Issued NMSS Information Notices

5. List of Recently Issued NRC Information Notices

ar.

Attachment 1 IN 95-50

October 30, 1995 B A R K E R+ T EC H - T I P

DATE: November 22. 1994 TO: All GAMMAMED 12i Users

FROM: Garry Nixon - U.S. GAMMAMED Service Manager

RE: GAMMAMED 12i Bronchial Catheters and Clamping Adapters

For the safest operation of your GAMMAMED 12i HDR unit please follow the following

procedures when using the white 1.8mm bronchial catheter with its associated damping

adapter.

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 it

firmly on the catheter,

6) now inset the damping adapter Into the treatment head.

Old Stc

alamping Adapter

hold pull to lock

hace

Uew Style

Camping Adapter

hold_ pull to loclc

heme

In order to avoid the catheter being pulled from the damping adapter In the case of the

patient moving, insure that slack exists in the catheter between the patent and the HOR

treatment head. This will be facilitated by positioning the tre3anent unit as near ac Is

possible to the patient.

If you have any questions please contact me at our toll-free number 1-800-2-BARKER

a - -

Attachment 2 IN 95-50

October 30, 1995 BARKER+ TECH-TIP

DATE: July 18, 1995 TO: Al Gammmed 12i Users

FROM: Garry Nixon - U.S. Iammned Service Manager

RE: Bronclal catheters to be used p in indexer chamncls 20 -24 I would like to remind all Gtmamed 12i Users that whaeever using the white 1.8mm

bronchial 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 pushing

against the end of the catheter, it will push the catheter almost completely out of the meul

clamping adapte which connects the catheter to the 12i's indexer channeL It is possible

that the source could complet.ly pubh the cathctcr out of the clamping adaptcr which

would result in the clanping adapter no longer clamping on the catheter but rather

clamping on the source wire! During the next movement of the source wire, the

abnormally high amount of frictin (between the cliapiig auapter and the source wire)

will be detected and an Emergency Ret will be initiated, thus terminating the

treatment. lf; during this Emergency Reawt, the wire becomes saLk in Lhe clump, it may

not be possible to completely retact the source capsule into it's "safe' position in the

depleted uranium shielding. This obviously would necessitate intervention within the

nmument room by the Radiation Oncology staff conducting the treatment, to evacuate the

patent; and by a BARKER+ Servce Egineer to retrieve the source into the shielding or

a shipping container.

In o to avoid this scrio,it iiimp at s adapter b used in indexer

channels 1-19. ThcIc ubwwels ae pvogmramcd to do an end t1st with c dummy

before extending the source wire. Chnels 20-24 do not do this end test and were

designed 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 3 IN 95-50

October 30, 1995 BARKER+

Sales and Marketing Division

33 JacktsonvlltG Road, Bldg.#1 Towaco, NJ 07082 Phone: (800) 222-7637 FAX.: (201) 335-1225 Date: August 18, 1995 To:

ATTN:'

From:Jeff Stickler

Number of Pages including this one: 1 all 12i Users that are presently usinq

the

Frank Rarker Associates. Inc. hereby advises new style, to discontinue use of

number 931-012, either old style or

12i damping adapter, product would

treating a patient using these adapters. we

these adapters. However. if ynt Art presently if you have one and or; 2)

advise that you finish treatments: 1)using the old style adapter

which we supplied to hp nprtain that the adapter is in the locked position.

following the Tech Tops

the NR(^ and the manufacturer.

This docision was made after discussion with which will become available in

in production

ITSiGAMAMED has a new clamping adapter of these specific adapters free of charge tn

the

Octor 1096. At tfat time we will replace any

Users.

please contact Jeff Stickier at the above

If you have any questions regarding this matter

convenience.

toll-free number and exton5o;n. 608 ot your

Respectfully, jusfley C. Sticger

Oirector Customer Support

Extension 608

a .

Attachment 4 IN 95-50

October 30, 1995 LIST OF RECENTLY ISSUED

NMSS INFORMATION NOTICES

Information Date of

Notice No. Subject Issuance Issued to

95-44 Ensuring Combatible Use of 09/26/95 All Radiography Licensees.

Drive Cables Incorporating

Industrial Nuclear Company

Ball-type Male Conectors

95-39 Brachytherapy Incidents 09/19/95 All U.S. Nuclear Regulatory

Involving Treatment Commission Medical

Planning Errors Licensees.

95-29 Oversight of Design and 06/07/95 All holders of OLs or CPs

and Fabrication Activities for nuclear power reactors.

for Metal Components Used

in Spent Fuel Dry Storage Independent spent fuel

Systems storage installation

designers and fabricators.

95-28 Emplacement of Support 06/05/95 All holders of OLs or CPs

Pads for Spent Fuel Dry for nuclear power reactors

Storage Installations at

Reactor Sites

95-25 Valve Failure during 05/11/95 All U.S. Nuclear Regulatory

Patient Treatment with Commission Medical

Gamma Stereotactic Licensees.

Radiosurgery Unit

94-64, Reactivity Insertion Trans- 04/06/95 All holders of OLs or CPs

Supp. 1 ient and Accident Limits for Nuclear Power Reactors

for High Burnup Fuel and all fuel fabrication

licensees.

95-07 Radiopharmaceutical Vial 01/27/95 All U.S. Nuclear Regulatory

Breakage during Preparation Commission medical licensees

authorized to use byproduct

material for diagnostic

procedures.

95-01 DOT Safety Advisory: 01/04/95 All U.S. Nuclear Regulatory

High Pressure Aluminum Commission licensees.

Seamless and Aluminum

Composite Hoop-Wrapped

Cylinders

K-,

V 6 .

Attachment 5 IN 95-50

October 30, 1995 Page I of 1 LIST OF RECENTLY ISSUED

NRC INFORMATION NOTICES

Information Date of

Notice No. Subject Issuance Issued to

95-49 Seismic Adequacy of 10/27/95 All holders of OLs or CPs

Thermo-Lag Panel s for nuclear power reactors.

95-48 Results of Shift Staffing 10/10/95 All holders of OLs or CPs

Study for nuclear power reactors.

95-47 Unexpected Opening of a 10/04/95 All holders of OLs or CPs

Safety/Relief Valve and for nuclear power reactors.

Complications Involving

Suppression Pool Cooling

Strainer Blockage

95-46 Unplanned, Undetected 10/06/95 All holders of OLs or CPs

Release of Radioactivity for nuclear power reactors.

from the Exhaust Ventilation

System of a Boiling Water

Reactor

95-12, Potentially Nonconforming 10/05/95 All holders of OLs or CPs

Supp. 1 Fasteners Supplied by for nuclear power reactors.

A&G Engineering II, Inc.

95-45 American Power Service 10/04/95 All holders of OLs or CPs

Falsification of American for nuclear power reactors.

Society for Nondestructive

Testing (ASNT) Certificates

95-44 Ensuring Compatible Use of 09/26/95 All Radiography Licensees.

Drive Cables Incorporating

Industrial Nuclear Company

Ball-Type Male Connectors

95-43 Failure of the Bolt-Locking 09/28/95 All holders of OLs or CPs

Device on the Reactor for nuclear power reactors

Coolant Pump Turning Vane designed by Westinghouse

Electric Corporation (W).

95-42 Commission Decision on the 09/22/95 All holders of OLs or CPs

Resolution of Generic for nuclear power reactors.

Issue 23, NReactor Coolant

Pump Seal Failure'

OL - Operating License

CP - Construction Permit