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| | issue date = 07/06/1999 | | | issue date = 07/06/1999 |
| | title = Safety Concerns Related to Repeated Control Unit Failures of the Nucletron Classic Model High-Dose-Rate Remote Afterloading Brachytherapy Devices | | | title = Safety Concerns Related to Repeated Control Unit Failures of the Nucletron Classic Model High-Dose-Rate Remote Afterloading Brachytherapy Devices |
| | author name = Cool D A | | | author name = Cool D |
| | author affiliation = NRC/NMSS/IMNS | | | author affiliation = NRC/NMSS/IMNS |
| | addressee name = | | | addressee name = |
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| | page count = 9 | | | page count = 9 |
| }} | | }} |
| {{#Wiki_filter:UNITED STATESNUCLEAR REGULATORY COMMISSIONOFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDSWASHINGTON, D.C. 20555-0001July 6, 1999NRC INFORMATION NOTICE 99-23: SAFETY CONCERNS RELATED TO REPEATEDCONTROL UNIT FAILURES OF THE NUCLETRONCLASSIC MODEL HIGH-DOSE-RATE REMOTEAFTERLOADING BRACHYTHERAPY DEVICES | | {{#Wiki_filter:UNITED STATES |
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| | NUCLEAR REGULATORY COMMISSION |
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| | OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS |
| | |
| | WASHINGTON, D.C. 20555-0001 July 6, 1999 NRC INFORMATION NOTICE 99-23: SAFETY CONCERNS RELATED TO REPEATED |
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| | CONTROL UNIT FAILURES OF THE NUCLETRON |
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| | CLASSIC MODEL HIGH-DOSE-RATE REMOTE |
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| | AFTERLOADING BRACHYTHERAPY DEVICES |
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| ==Addressees== | | ==Addressees== |
| :All U.S. Nuclear Regulatory Commission (NRC) medical licensees authorized to usebrachytherapy sources in Nucletron Classic Model high-dose-rate (HDR) remote afterloaders. | | : |
| | authorized to use |
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| | All U.S. Nuclear Regulatory Commission (NRC) medical licensees |
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| | remote afterloaders. |
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| | brachytherapy sources in Nucletron Classic Model high-dose-rate (HDR) |
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| ==Purpose== | | ==Purpose== |
| :NRC is issuing this information notice to alert you to ongoing control unit failures with NucletronClassic Model HDR devices. You should review this information for applicability to your facilitiesand consider actions, as appropriate, to minimize the impact of such failures on patienttreatments and personnel exposures. However, suggestions contained in this information noticeare not NRC requirements; therefore, no specific action nor written response is required. | | : |
| | unit failures with Nucletron |
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| | NRC is issuing this information notice to alert you to ongoing control to your facilities |
| | |
| | for applicability |
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| | Classic Model HDR devices. You should review this information patient |
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| | failures on |
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| | and consider actions, as appropriate, to minimize the impact of such |
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| | suggestions contained in this information notice |
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| | treatments and personnel exposures. However, response is required. |
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| | are not NRC requirements; therefore, no specific action nor written |
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| ==Description of Circumstances== | | ==Description of Circumstances== |
| :By January 1996, NRC was aware of three incidents where the Nucletron Classic Model HDRcontrol units failed (locked up) for unexplained reasons. These control unit failures exposed adeficiency in the design of the door interlock circuitry for the Nucletron Classic Model HDR.Nucletron issued a Safety Alert on March 4, 1996, describing this problem and providinginformation on the proper operator response to such failures. This safety alert was also issuedas an attachment to NRC Information Notice 96-21, issued on April 10, 1996, that discussedboth the door interlock problem and the control unit failures. Following these three reportedfailures of the control unit, Nucletron Corporation made field modifications to these devices tocorrect the door interlock failure mechanism and to eliminate the unexplained control unitfailures.Following these modifications, two similar failures were reported in 1997, four in 1998, and threeto date in 1999. These additional nine control unit failures, reported since the 1996 correctiveaction, indicate a ongoing problem with unexplained control unit failures. However, no furtherproblems have been reported with the operation of the door interlocks. Nucletron has continuedto investigate the ongoing control unit failures and now believes it has found the root cause ofthe failures and subsequently developed appropriate corrective measures. We understand thatthe newly developed corrective measures are presently undergoing testing beforeimplementation.0t rn4-] dwotaqq-O2s q4o1o -o4cW c eas | | : |
| | Classic Model HDR |
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| | By January 1996, NRC was aware of three incidents where the Nucletron |
| | |
| | unit failures exposed a |
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| | control units failed (locked up) for unexplained reasons. These control |
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| | Classic Model HDR. |
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| | deficiency in the design of the door interlock circuitry for the Nucletron |
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| | and providing |
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| | Nucletron issued a Safety Alert on March 4, 1996, describing this problem |
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| | This safety alert was also issued |
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| | information on the proper operator response to such failures. discussed |
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| | 10, 1996, that |
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| | as an attachment to NRC Information Notice 96-21, issued on April |
| | |
| | these three reported |
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| | both the door interlock problem and the control unit failures. Following |
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| | field modifications to these devices to |
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| '-IIN 99-23July 6, 1999 Discussion:In all 12 reported control unit failures no patient or personnel overexposures were reported. Ineach case the treatment unit continued to operate, as designed, when communications with thecontrol unit was lost. In this event, the microprocessor in the treatment unit continues thepreprogrammed treatment to the catheter being treated when the failure occurs, halting uponcompletion. If the failure occurs during a single catheter treatment or during the last catheter ina multi-catheter operation, then the treatment will proceed to completion. Otherwise, it willterminate with completion of the catheter being treated, leaving any remaining cathetersuntreated. Most users, however, when faced with a blank or frozen display on an inoperativecontrol unit, immediately abort the treatment, using the "Emergency Stop" button on the controlunit. The "Treatment Interrupt" button (called for in the 1" step on the Safety Alert procedures)on the control unit is rendered inoperative by the control unit failure. Irrespective of the methodof terminating the patient's treatment, the actual treatment data can subsequently be read fromthe treatment unit, using a handheld terminal device.Most patients receive less than the prescribed dose in the event of a control unit failure and, atthe discretion of the Authorized User, either the Written Directive must be revised to reflect theactual dose given or the remaining portion of the treatment given after repair or replacement ofthe defective control unit. To date, none of the reported control unit failures has resulted inoverexposures or misadministrations. However, the failure of the control unit removes the firstlayer of radiation safety protection. At this point, the avoidance of excessive radiation exposuresdepends upon either the continued proper operation of the treatment unit or operatorintervention.NRC previously issued Information Notice 96-21 on April 10, 1996, and included a copy of theNucletron issued Safety Alert, addressing the control unit failures, as an attachment. This SafetyAlert sets forth a series of four steps to be taken if, for any reason, the Control Unit stopsupdating the status of the treatment in progress. These steps should ensure that the treatmentis interrupted and the source retracted before licensee personnel enter the treatment room. Youare encouraged to follow these recommendations from the device vendor, as contained in itsSafety Alert of March 4, 1996. Any questions you may have related to these control unit failuresand related corrective actions, or to get a copy of the Safety Alert, should be addressed to yourNucletron Corporation representative.
| | failures of the control unit, Nucletron Corporation made |
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| IN 99-23July 6, 1999 This information notice requires no specific action nor written response. If you have anyquestions about the information in this notice, please contact the technical contact listed belowor the appropriate regional office.Donald A. Cool, DirectorDivision of Industrial andMedical Nuclear SafetyOffice of Nuclear Material Safetyand SafeguardsContact: Robert L. Ayres, NMSS(301) 415-5746E-mail: rxal nrc.govAttachments:1. List of Recently Issued NMSS Information Notices2. List of Recently Issued NRC Information NoticesItWt4 a,-TV
| | unexplained control unit |
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| K-'IAttachment 1IN 99-23July 6, 1999 LIST OF RECENTLY ISSUEDNMSS INFORMATION NOTICESInformation Date ofNotice No. Subject Issuance Issued to99-22 10 CFR 34.43(a)(1): Effective 6/25/99 Industrial Radiography LicenseesDate for Radiographer Certificationand Plans for Enforcement Discretion99-2099-1899-16-99-1199-0999-0699-0599-0499-03Contingency Planning for the 6/25/99Year 2000 Computer ProblemUpdate on NRC's Year 2000 6/14/99Activities for Materials Licenseesand Fuel Cycle Licensees andCertificate HoldersFederal Bureau of Investigation's 5/28Nuclear Site Security ProgramIncident Involving the Use of 4/16199Radioactive lodine-1 31Problems Encountered When 3/24/99Manually Editing treatment Dataon the Nucletron Microselectron-HDR (New) Model 105-9991998 Enforcement Sanctions as 3/19/99a Result of Deliberate Violationsof NRC Employee ProtectionRequirementsInadvertent Discharge of Carbon 3/8/99Dioxide Fire Protection Systemand Gas MigrationUnplanned Radiation Exposures 3/8/99to Radiographers, Resulting FromFailures to Follow Proper RadiationSafety ProceduresExothermic Reactions Involving 1/29/99Dried Uranium Oxide Powder(Yellowcake)All material and fuel cyclelicensees and certificate holdersAll material and fuel cyclelicensees and certificateholdersAll U.S. Nuclear RegulatoryCommission fuel cycle, powerreactor, and non-power reactorlicenseesAll medical use licenseesAll medical licensees authorizedto conduct high-dose-rate (HDR)remote after loadingbrachytherapy treatmentsAll U. S. Nuclear RegulatoryCommission licenseesAll holders of licenses for nuclearpower, research, and test reactor,and fuel cycle facilitiesAll radiography licenseesAll operating uranium recoveryfacilities that produce oxidepowder (U308) (yellowcake)
| | correct the door interlock failure mechanism and to eliminate the |
| v>Attachment 2IN 99-23July 6, 1999 LIST OF RECENTLY ISSUEDNRC INFORMATION NOTICESInformation Date ofNotice No. Subject Issuance Issued to99-22 10 CFR 34.43(a)(1); Effective 7/6/99 Industrial Radiography LicenseesDate for Radiographer Certificationand Plans for Enforcement Discretion99-2199-2099-1999-1899-1799-16-99-15Recent Plant Events CausedBy Human Performance ErrorsContingency Planning for theYear 200 Computer ProblemRupture of the Shell Side of aFeedwater Heater at the PointBeach Nuclear PlantUpdate on NRC's Year 2000Activities for Materials Licenseesand Fuel Cycle Licensees andCertificate Holders6/25/996/25/996/23/996/14/99All holders of licenses for nuclearpower, test, and research reactorsAll material and fuel cyclelicensees and certificate holdersAll holders of operating licensesor construction permits for nuclearpower reactorsAll material and fuel cyclelicensees and certificate holdersAll holders of OL for nuclearpower reactors, except those whohave permanently ceasedoperations and have certified thatthe fuel has been permanentlyremoved from the reactorAll U.S. Nuclear RegulatoryCommission fuel cycle, powerreactor, and non-power reactorlicenseesAll holders of operating licenses orconstruction permits for nuclearpower reactorsProblems Associated with Post-Fire 6/3/99Safe-Shutdown Circuit AnalysesFederal Bureau of Investigation's 5/28Nuclear Site Security ProgramMisapplication of 10 CFR Part 71Transportation Shipping CaskLicensing Basis to 10 CFR Part 50Design Basis5/27/99OL = Operating LicenseCP = Construction Permit
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| <lI-1,-23>, 6, 1999 This information notice requires no specific action nor written response. If you have anyquestions about the information in this notice, please contact the technical contact listed belowor the appropriate regional office.(ORIG. SIGNED BY)Donald A. Cool, DirectorDivision of Industrial andMedical Nuclear SafetyOffice of Nuclear Material Safetyand SafeguardsContact: Robert L. Ayres, NMSS(301) 415-5746E-mail: rxal nrc.govAttachments:1. List of Recently Issued NMSS Information Notices2. List of Recently Issued NRC Information NoticesDOCUMENT NAME: A & G:%AYRES\IN99C-XX.WPD* See previous concurrenceOFFICE JMSIB C Editor* I MSIB* N Ms MSIB* I NNAME RAyres/liucy EKraus FSturz LCamper DCoolDATE 6/ 09 /99 6109 /99 6115/99 6/15/99 6/28/99s ^=rloEIf AI aMen n rn0PVA4~w O r K~~~AML REGO~ I u %L W
| | failures. |
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| IN 99-XXAJ June XX, 1999
| | four in 1998, and three |
| .z~ IN 99-XXJune xx, 1999 DOCUMENT NAME: A & G:\AYRES\IN99C-XX.WPDtfqff /£fL411V5. --/ 0 :"//* See orevious concurrenceOFFICE MSIB C Editor I MSIB MSIB N MSIB l NN /NAME RAyres/jcy EKraus FSturz LCamper DCooI ,,DATE 16/ 9 /99 6/ 09 /99 6/ IU< /99 6/ IS /99 16/ ,199OFFICIAL RECORD COPYI//',,Ii
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| 6I~-IN 99-XXL/ June xx, 1999 DOCUMENT NAME: A & G:\AYRES\1N99C-XX.WPD* See previous concurrenceOFFICE _ SBIC Eio*I M~- S9fIN MINAME RAyres/kicy EKraus D -erCoolDATE 1 6/ 09 /99 6/09 /99 Is__ 199 6/ ____99__ 6/ /99OFFICIAL RECORD COPY
| | Following these modifications, two similar failures were reported in 1997, since the 1996 corrective |
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| }} | | to date in 1999. These additional nine control unit failures, reported |
| | |
| | However, no further |
| | |
| | action, indicate a ongoing problem with unexplained control unit failures. has continued |
| | |
| | interlocks. Nucletron |
| | |
| | problems have been reported with the operation of the door cause of |
| | |
| | the root |
| | |
| | to investigate the ongoing control unit failures and now believes it has found |
| | |
| | We understand that |
| | |
| | the failures and subsequently developed appropriate corrective measures. |
| | |
| | before |
| | |
| | the newly developed corrective measures are presently undergoing testing |
| | |
| | implementation. |
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| | c |
| | |
| | 0t rn4-] dwotaqq-O2s q4o1o |
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| | eas |
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| | -o4 cW |
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| | '-I |
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| | IN 99-23 July 6, 1999 Discussion: |
| | were reported. In |
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| | In all 12 reported control unit failures no patient or personnel overexposures |
| | |
| | when communications with the |
| | |
| | each case the treatment unit continued to operate, as designed, unit continues the |
| | |
| | control unit was lost. In this event, the microprocessor in the treatment |
| | |
| | the failure occurs, halting upon |
| | |
| | preprogrammed treatment to the catheter being treated when |
| | |
| | or during the last catheter in |
| | |
| | completion. If the failure occurs during a single catheter treatment Otherwise, it will |
| | |
| | a multi-catheter operation, then the treatment will proceed to completion. catheters |
| | |
| | any remaining |
| | |
| | terminate with completion of the catheter being treated, leaving on an inoperative |
| | |
| | display |
| | |
| | untreated. Most users, however, when faced with a blank or frozen |
| | |
| | Stop" button on the control |
| | |
| | control unit, immediately abort the treatment, using the "Emergency |
| | |
| | on the Safety Alert procedures) |
| | unit. The "Treatment Interrupt" button (called for in the 1" step |
| | |
| | Irrespective of the method |
| | |
| | on the control unit is rendered inoperative by the control unit failure. |
| | |
| | can subsequently be read from |
| | |
| | of terminating the patient's treatment, the actual treatment data |
| | |
| | the treatment unit, using a handheld terminal device. |
| | |
| | of a control unit failure and, at |
| | |
| | Most patients receive less than the prescribed dose in the event |
| | |
| | must be revised to reflect the |
| | |
| | the discretion of the Authorized User, either the Written Directive |
| | |
| | after repair or replacement of |
| | |
| | actual dose given or the remaining portion of the treatment given |
| | |
| | unit failures has resulted in |
| | |
| | the defective control unit. To date, none of the reported control |
| | |
| | the control unit removes the first |
| | |
| | overexposures or misadministrations. However, the failure of |
| | |
| | of excessive radiation exposures |
| | |
| | layer of radiation safety protection. At this point, the avoidance |
| | |
| | unit or operator |
| | |
| | depends upon either the continued proper operation of the treatment |
| | |
| | intervention. |
| | |
| | and included a copy of the |
| | |
| | NRC previously issued Information Notice 96-21 on April 10, 1996, as an attachment. This Safety |
| | |
| | Nucletron issued Safety Alert, addressing the control unit failures, the Control Unit stops |
| | |
| | Alert sets forth a series of four steps to be taken if, for any reason, should ensure that the treatment |
| | |
| | updating the status of the treatment in progress. These steps |
| | |
| | enter the treatment room. You |
| | |
| | is interrupted and the source retracted before licensee personnel |
| | |
| | vendor, as contained in its |
| | |
| | are encouraged to follow these recommendations from the device |
| | |
| | to these control unit failures |
| | |
| | Safety Alert of March 4, 1996. Any questions you may have related |
| | |
| | should be addressed to your |
| | |
| | and related corrective actions, or to get a copy of the Safety Alert, Nucletron Corporation representative. |
| | |
| | IN 99-23 July 6, 1999 If you have any |
| | |
| | This information notice requires no specific action nor written response. |
| | |
| | technical contact listed below |
| | |
| | questions about the information in this notice, please contact the |
| | |
| | or the appropriate regional office. |
| | |
| | Donald A. Cool, Director |
| | |
| | Division of Industrial and |
| | |
| | Medical Nuclear Safety |
| | |
| | Office of Nuclear Material Safety |
| | |
| | and Safeguards |
| | |
| | Contact: Robert L. Ayres, NMSS |
| | |
| | (301) 415-5746 E-mail: rxal nrc.gov |
| | |
| | Attachments: |
| | 1. List of Recently Issued NMSS Information Notices |
| | |
| | 2. List of Recently Issued NRC Information Notices |
| | |
| | ItWt4 a,-TV |
| | |
| | K-' I |
| | |
| | Attachment 1 IN 99-23 July 6, 1999 LIST OF RECENTLY ISSUED |
| | |
| | NMSS INFORMATION NOTICES |
| | |
| | Information Date of |
| | |
| | Subject Issuance Issued to |
| | |
| | Notice No. |
| | |
| | 10 CFR 34.43(a)(1): Effective 6/25/99 Industrial Radiography Licensees |
| | |
| | 99-22 Date for Radiographer Certification |
| | |
| | and Plans for Enforcement Discretion |
| | |
| | 6/25/99 All material and fuel cycle |
| | |
| | 99-20 Contingency Planning for the |
| | |
| | Year 2000 Computer Problem licensees and certificate holders |
| | |
| | Update on NRC's Year 2000 6/14/99 All material and fuel cycle |
| | |
| | 99-18 Activities for Materials Licensees licensees and certificate |
| | |
| | and Fuel Cycle Licensees and holders |
| | |
| | Certificate Holders |
| | |
| | Federal Bureau of Investigation's 5/28 All U.S. Nuclear Regulatory |
| | |
| | 99-16- Nuclear Site Security Program Commission fuel cycle, power |
| | |
| | reactor, and non-power reactor |
| | |
| | licensees |
| | |
| | Incident Involving the Use of 4/16199 All medical use licensees |
| | |
| | 99-11 Radioactive lodine-1 31 Problems Encountered When 3/24/99 All medical licensees authorized |
| | |
| | 99-09 to conduct high-dose-rate (HDR) |
| | Manually Editing treatment Data |
| | |
| | on the Nucletron Microselectron- remote after loading |
| | |
| | HDR (New) Model 105-999 brachytherapy treatments |
| | |
| | 1998 Enforcement Sanctions as 3/19/99 All U. S. Nuclear Regulatory |
| | |
| | 99-06 Commission licensees |
| | |
| | a Result of Deliberate Violations |
| | |
| | of NRC Employee Protection |
| | |
| | Requirements |
| | |
| | Inadvertent Discharge of Carbon 3/8/99 All holders of licenses for nuclear |
| | |
| | 99-05 power, research, and test reactor, Dioxide Fire Protection System |
| | |
| | and fuel cycle facilities |
| | |
| | and Gas Migration |
| | |
| | Unplanned Radiation Exposures 3/8/99 All radiography licensees |
| | |
| | 99-04 to Radiographers, Resulting From |
| | |
| | Failures to Follow Proper Radiation |
| | |
| | Safety Procedures |
| | |
| | Exothermic Reactions Involving 1/29/99 All operating uranium recovery |
| | |
| | 99-03 Dried Uranium Oxide Powder facilities that produce oxide |
| | |
| | (Yellowcake) powder (U308) (yellowcake) |
| | |
| | v> Attachment 2 IN 99-23 July 6, 1999 LIST OF RECENTLY ISSUED |
| | |
| | NRC INFORMATION NOTICES |
| | |
| | Information Date of |
| | |
| | Subject Issuance Issued to |
| | |
| | Notice No. |
| | |
| | 99-22 10 CFR 34.43(a)(1); Effective 7/6/99 Industrial Radiography Licensees |
| | |
| | Date for Radiographer Certification |
| | |
| | and Plans for Enforcement Discretion |
| | |
| | Recent Plant Events Caused 6/25/99 All holders of licenses for nuclear |
| | |
| | 99-21 power, test, and research reactors |
| | |
| | By Human Performance Errors |
| | |
| | 6/25/99 All material and fuel cycle |
| | |
| | 99-20 Contingency Planning for the |
| | |
| | Year 200 Computer Problem licensees and certificate holders |
| | |
| | Rupture of the Shell Side of a 6/23/99 All holders of operating licenses |
| | |
| | 99-19 or construction permits for nuclear |
| | |
| | Feedwater Heater at the Point |
| | |
| | Beach Nuclear Plant power reactors |
| | |
| | Update on NRC's Year 2000 6/14/99 All material and fuel cycle |
| | |
| | 99-18 licensees and certificate holders |
| | |
| | Activities for Materials Licensees |
| | |
| | and Fuel Cycle Licensees and |
| | |
| | Certificate Holders |
| | |
| | Problems Associated with Post-Fire 6/3/99 All holders of OL for nuclear |
| | |
| | 99-17 Safe-Shutdown Circuit Analyses power reactors, except those who |
| | |
| | have permanently ceased |
| | |
| | operations and have certified that |
| | |
| | the fuel has been permanently |
| | |
| | removed from the reactor |
| | |
| | Federal Bureau of Investigation's 5/28 All U.S. Nuclear Regulatory |
| | |
| | 99-16- Nuclear Site Security Program Commission fuel cycle, power |
| | |
| | reactor, and non-power reactor |
| | |
| | licensees |
| | |
| | Misapplication of 10 CFR Part 71 5/27/99 All holders of operating licenses or |
| | |
| | 99-15 construction permits for nuclear |
| | |
| | Transportation Shipping Cask |
| | |
| | Licensing Basis to 10 CFR Part 50 power reactors |
| | |
| | Design Basis |
| | |
| | OL = Operating License |
| | |
| | CP = Construction Permit |
| | |
| | -1,-23 |
| | <lI >, 6, 1999 response. If you have any |
| | |
| | This information notice requires no specific action nor written |
| | |
| | the technical contact listed below |
| | |
| | questions about the information in this notice, please contact |
| | |
| | or the appropriate regional office. |
| | |
| | (ORIG. SIGNED BY) |
| | Donald A. Cool, Director |
| | |
| | Division of Industrial and |
| | |
| | Medical Nuclear Safety |
| | |
| | Office of Nuclear Material Safety |
| | |
| | and Safeguards |
| | |
| | Contact: Robert L. Ayres, NMSS |
| | |
| | (301) 415-5746 E-mail: rxal nrc.gov |
| | |
| | Attachments: |
| | 1. List of Recently Issued NMSS Information Notices |
| | |
| | 2. List of Recently Issued NRC Information Notices |
| | |
| | DOCUMENT NAME: A & G:%AYRES\IN99C-XX.WPD |
| | |
| | * See previous concurrence |
| | |
| | MSIB* IN |
| | |
| | OFFICE JMSIB C Editor* I MSIB* Ms N |
| | |
| | EKraus FSturz LCamper DCool |
| | |
| | NAME RAyres/liucy |
| | |
| | 6109 /99 6115/99 6/15/99 6/28/99 DATE 6/ 09 /99 n rn0PV |
| | |
| | A4~w^=rloEIf |
| | |
| | s |
| | |
| | O |
| | |
| | AI aMen |
| | |
| | r K~~~AMLREGO~ I %L u |
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| | W |
| | |
| | IN 99-XX |
| | |
| | AJ June XX, 1999 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 |
| | |
| | Contact: Robert L. Ayres, NMSS |
| | |
| | (301) 415-5746 E-mail: rxal @nrc.gov / |
| | Attachments: |
| | 1. List of Recently Issued NMSS Information Notices |
| | |
| | 2. List of Recently Issued NRC Information Notices A |
| | |
| | ''</ |
| | / |
| | DOCUMENT NAME: A & G:\AYRES\IN99C-XX.WPD |
| | |
| | * See previous concurrence |
| | |
| | OFFICE MSIB IC Editor I MSIB* I lISIB l MSIB IN |
| | |
| | NAME RAyrestic EKraus FSturz LCamper DC_______ |
| | DATE 6/ 09 /99 6/09 /99 6/15/99 6/15/99 6/.t1/99 OFFICIAL RECORD COPY |
| | |
| | .z~ IN 99-XX |
| | |
| | June xx, 1999 DOCUMENT NAME: A & G:\AYRES\IN99C-XX.WPD tfqff / |
| | £fL411V5.--/0 :"// |
| | |
| | * See orevious concurrence |
| | |
| | OFFICE MSIB C Editor I MSIB MSIB N MSIB l NN/ |
| | NAME RAyres/jcy EKraus FSturz LCamper DCooI |
| | |
| | ,, |
| | DATE 16/ 9 /99 6/ 09 /99 6/ IU< /99 6/ IS /99 16/ ,199 OFFICIAL RECORD COPY |
| | |
| | I/ |
| | /' |
| | , |
| | , |
| | Ii |
| | |
| | 6 I~- IN 99-XX |
| | |
| | L/ June xx, 1999 DOCUMENT NAME: A & G:\AYRES\1N99C-XX.WPD |
| | |
| | * See previous concurrence |
| | |
| | OFFICE _ SBIC Eio*I M~- S9fIN MI |
| | |
| | NAME RAyres/kicy EKraus - erCool D |
| | |
| | DATE 16/ 09 /99 6/09 /99 Is__ 199 6/ |
| | ____99__ 6/ /99 OFFICIAL RECORD COPY}} |
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| {{Information notice-Nav}} | | {{Information notice-Nav}} |
Safety Concerns Related to Repeated Control Unit Failures of the Nucletron Classic Model High-Dose-Rate Remote Afterloading Brachytherapy DevicesML031040399 |
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: |
07/06/1999 |
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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-99-023, NUDOCS 9907010001 |
Download: ML031040399 (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 Contamination2006-07-13013 July 2006 E-mail from M. 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>. |
UNITED STATES
NUCLEAR REGULATORY COMMISSION
OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS
WASHINGTON, D.C. 20555-0001 July 6, 1999 NRC INFORMATION NOTICE 99-23: SAFETY CONCERNS RELATED TO REPEATED
CONTROL UNIT FAILURES OF THE NUCLETRON
CLASSIC MODEL HIGH-DOSE-RATE REMOTE
AFTERLOADING BRACHYTHERAPY DEVICES
Addressees
authorized to use
All U.S. Nuclear Regulatory Commission (NRC) medical licensees
remote afterloaders.
brachytherapy sources in Nucletron Classic Model high-dose-rate (HDR)
Purpose
unit failures with Nucletron
NRC is issuing this information notice to alert you to ongoing control to your facilities
for applicability
Classic Model HDR devices. You should review this information patient
failures on
and consider actions, as appropriate, to minimize the impact of such
suggestions contained in this information notice
treatments and personnel exposures. However, response is required.
are not NRC requirements; therefore, no specific action nor written
Description of Circumstances
Classic Model HDR
By January 1996, NRC was aware of three incidents where the Nucletron
unit failures exposed a
control units failed (locked up) for unexplained reasons. These control
Classic Model HDR.
deficiency in the design of the door interlock circuitry for the Nucletron
and providing
Nucletron issued a Safety Alert on March 4, 1996, describing this problem
This safety alert was also issued
information on the proper operator response to such failures. discussed
10, 1996, that
as an attachment to NRC Information Notice 96-21, issued on April
these three reported
both the door interlock problem and the control unit failures. Following
field modifications to these devices to
failures of the control unit, Nucletron Corporation made
unexplained control unit
correct the door interlock failure mechanism and to eliminate the
failures.
four in 1998, and three
Following these modifications, two similar failures were reported in 1997, since the 1996 corrective
to date in 1999. These additional nine control unit failures, reported
However, no further
action, indicate a ongoing problem with unexplained control unit failures. has continued
interlocks. Nucletron
problems have been reported with the operation of the door cause of
the root
to investigate the ongoing control unit failures and now believes it has found
We understand that
the failures and subsequently developed appropriate corrective measures.
before
the newly developed corrective measures are presently undergoing testing
implementation.
c
0t rn4-] dwotaqq-O2s q4o1o
eas
-o4 cW
'-I
IN 99-23 July 6, 1999 Discussion:
were reported. In
In all 12 reported control unit failures no patient or personnel overexposures
when communications with the
each case the treatment unit continued to operate, as designed, unit continues the
control unit was lost. In this event, the microprocessor in the treatment
the failure occurs, halting upon
preprogrammed treatment to the catheter being treated when
or during the last catheter in
completion. If the failure occurs during a single catheter treatment Otherwise, it will
a multi-catheter operation, then the treatment will proceed to completion. catheters
any remaining
terminate with completion of the catheter being treated, leaving on an inoperative
display
untreated. Most users, however, when faced with a blank or frozen
Stop" button on the control
control unit, immediately abort the treatment, using the "Emergency
on the Safety Alert procedures)
unit. The "Treatment Interrupt" button (called for in the 1" step
Irrespective of the method
on the control unit is rendered inoperative by the control unit failure.
can subsequently be read from
of terminating the patient's treatment, the actual treatment data
the treatment unit, using a handheld terminal device.
of a control unit failure and, at
Most patients receive less than the prescribed dose in the event
must be revised to reflect the
the discretion of the Authorized User, either the Written Directive
after repair or replacement of
actual dose given or the remaining portion of the treatment given
unit failures has resulted in
the defective control unit. To date, none of the reported control
the control unit removes the first
overexposures or misadministrations. However, the failure of
of excessive radiation exposures
layer of radiation safety protection. At this point, the avoidance
unit or operator
depends upon either the continued proper operation of the treatment
intervention.
and included a copy of the
NRC previously issued Information Notice 96-21 on April 10, 1996, as an attachment. This Safety
Nucletron issued Safety Alert, addressing the control unit failures, the Control Unit stops
Alert sets forth a series of four steps to be taken if, for any reason, should ensure that the treatment
updating the status of the treatment in progress. These steps
enter the treatment room. You
is interrupted and the source retracted before licensee personnel
vendor, as contained in its
are encouraged to follow these recommendations from the device
to these control unit failures
Safety Alert of March 4, 1996. Any questions you may have related
should be addressed to your
and related corrective actions, or to get a copy of the Safety Alert, Nucletron Corporation representative.
IN 99-23 July 6, 1999 If you have any
This information notice requires no specific action nor written response.
technical contact listed below
questions about the information in this notice, please contact the
or the appropriate regional office.
Donald A. Cool, Director
Division of Industrial and
Medical Nuclear Safety
Office of Nuclear Material Safety
and Safeguards
Contact: Robert L. Ayres, NMSS
(301) 415-5746 E-mail: rxal nrc.gov
Attachments:
1. List of Recently Issued NMSS Information Notices
2. List of Recently Issued NRC Information Notices
ItWt4 a,-TV
K-' I
Attachment 1 IN 99-23 July 6, 1999 LIST OF RECENTLY ISSUED
NMSS INFORMATION NOTICES
Information Date of
Subject Issuance Issued to
Notice No.
10 CFR 34.43(a)(1): Effective 6/25/99 Industrial Radiography Licensees
99-22 Date for Radiographer Certification
and Plans for Enforcement Discretion
6/25/99 All material and fuel cycle
99-20 Contingency Planning for the
Year 2000 Computer Problem licensees and certificate holders
Update on NRC's Year 2000 6/14/99 All material and fuel cycle
99-18 Activities for Materials Licensees licensees and certificate
and Fuel Cycle Licensees and holders
Certificate Holders
Federal Bureau of Investigation's 5/28 All U.S. Nuclear Regulatory
99-16- Nuclear Site Security Program Commission fuel cycle, power
reactor, and non-power reactor
licensees
Incident Involving the Use of 4/16199 All medical use licensees
99-11 Radioactive lodine-1 31 Problems Encountered When 3/24/99 All medical licensees authorized
99-09 to conduct high-dose-rate (HDR)
Manually Editing treatment Data
on the Nucletron Microselectron- remote after loading
HDR (New) Model 105-999 brachytherapy treatments
1998 Enforcement Sanctions as 3/19/99 All U. S. Nuclear Regulatory
99-06 Commission licensees
a Result of Deliberate Violations
of NRC Employee Protection
Requirements
Inadvertent Discharge of Carbon 3/8/99 All holders of licenses for nuclear
99-05 power, research, and test reactor, Dioxide Fire Protection System
and fuel cycle facilities
and Gas Migration
Unplanned Radiation Exposures 3/8/99 All radiography licensees
99-04 to Radiographers, Resulting From
Failures to Follow Proper Radiation
Safety Procedures
Exothermic Reactions Involving 1/29/99 All operating uranium recovery
99-03 Dried Uranium Oxide Powder facilities that produce oxide
(Yellowcake) powder (U308) (yellowcake)
v> Attachment 2 IN 99-23 July 6, 1999 LIST OF RECENTLY ISSUED
NRC INFORMATION NOTICES
Information Date of
Subject Issuance Issued to
Notice No.
99-22 10 CFR 34.43(a)(1); Effective 7/6/99 Industrial Radiography Licensees
Date for Radiographer Certification
and Plans for Enforcement Discretion
Recent Plant Events Caused 6/25/99 All holders of licenses for nuclear
99-21 power, test, and research reactors
By Human Performance Errors
6/25/99 All material and fuel cycle
99-20 Contingency Planning for the
Year 200 Computer Problem licensees and certificate holders
Rupture of the Shell Side of a 6/23/99 All holders of operating licenses
99-19 or construction permits for nuclear
Feedwater Heater at the Point
Beach Nuclear Plant power reactors
Update on NRC's Year 2000 6/14/99 All material and fuel cycle
99-18 licensees and certificate holders
Activities for Materials Licensees
and Fuel Cycle Licensees and
Certificate Holders
Problems Associated with Post-Fire 6/3/99 All holders of OL for nuclear
99-17 Safe-Shutdown Circuit Analyses power reactors, except those who
have permanently ceased
operations and have certified that
the fuel has been permanently
removed from the reactor
Federal Bureau of Investigation's 5/28 All U.S. Nuclear Regulatory
99-16- Nuclear Site Security Program Commission fuel cycle, power
reactor, and non-power reactor
licensees
Misapplication of 10 CFR Part 71 5/27/99 All holders of operating licenses or
99-15 construction permits for nuclear
Transportation Shipping Cask
Licensing Basis to 10 CFR Part 50 power reactors
Design Basis
OL = Operating License
CP = Construction Permit
-1,-23
, 6, 1999 response. If you have any
This information notice requires no specific action nor written
the technical contact listed below
questions about the information in this notice, please contact
or the appropriate regional office.
(ORIG. SIGNED BY)
Donald A. Cool, Director
Division of Industrial and
Medical Nuclear Safety
Office of Nuclear Material Safety
and Safeguards
Contact: Robert L. Ayres, NMSS
(301) 415-5746 E-mail: rxal nrc.gov
Attachments:
1. List of Recently Issued NMSS Information Notices
2. List of Recently Issued NRC Information Notices
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AJ June XX, 1999 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
Contact: Robert L. Ayres, NMSS
(301) 415-5746 E-mail: rxal @nrc.gov /
Attachments:
1. List of Recently Issued NMSS Information Notices
2. List of Recently Issued NRC Information Notices A
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list | - Information Notice 1999-01, Deterioration of High-Efficiency Particulate Air Filters in a Pressurized Water Reactor Containment Fan Cooler Unit (20 January 1999)
- Information Notice 1999-02, Guidance to Users on the Implementation of a New Single-Source Dose-Calculation Formalism and Revised Air-Kerma Strength Standard for Iodine-125 Sealed Sources (21 January 1999, Topic: Brachytherapy)
- Information Notice 1999-03, Exothermic Reactors Involving Dried Uranium Oxide Powder (Yellowcake) (29 January 1999, Topic: Brachytherapy)
- Information Notice 1999-04, Unplanned Radiation Exposures to Radiographers, Resulting from Failures to Follow Proper Radiation Safety Procedures (1 March 1999, Topic: Brachytherapy)
- Information Notice 1999-05, Inadvertent Discharge of Carbon Dioxide Fire Protection System and Gas Migration (8 March 1999, Topic: Brachytherapy)
- Information Notice 1999-06, 1998 Enforcement Sanctions as a Result of Deliberate Violations of NRC Employee Protection Requirements (19 March 1999, Topic: Enforcement Discretion, Brachytherapy)
- Information Notice 1999-06, 1998 Enforcement Sanctions As a Result of Deliberate Violations of NRC Employee Protection Requirements (19 March 1999, Topic: Enforcement Discretion)
- Information Notice 1999-07, Failed Fire Protection Deluge Valves & Potential Testing Deficiencies in Preaction Sprinkler Systems (22 March 1999, Topic: Safe Shutdown)
- Information Notice 1999-08, Urine Specimen Adulteration (26 March 1999, Topic: Brachytherapy)
- Information Notice 1999-09, Problems Encountered When Manually Editing Treatment Data on the Nucletron Microselectron-HDR (New) Model 105-999 (24 March 1999, Topic: Brachytherapy)
- Information Notice 1999-10, Degradation of Prestressing Tendon Systems in Prestresssed Concrete Containments (13 April 1999)
- Information Notice 1999-11, Incidents Involving the Use of Radioactive Iodine-131 (16 April 1999, Topic: Brachytherapy)
- Information Notice 1999-12, Year 2000 Computer Systems Readiness Audits (28 April 1999, Topic: Brachytherapy)
- Information Notice 1999-13, Insights from NRC Inspections of Low-and Medium-Voltage Circuit Breaker Maintenance Programs (29 April 1999, Topic: Brachytherapy)
- Information Notice 1999-14, Unanticipated Reactor Water Draindown at Quad Cities Unit 2, Arkansas Nuclear One Unit 2, & FitzPatrick (5 May 1999, Topic: Reactor Vessel Water Level, Brachytherapy)
- Information Notice 1999-15, Misapplication for 10CFR Part 71 Transportation Shipping Cask Licensing Basis to 10CFR Part 50 Design Basis (27 May 1999, Topic: Brachytherapy)
- Information Notice 1999-16, Federal Bureau of Investigation'S Nuclear Site Security Program (28 May 1999, Topic: Brachytherapy)
- Information Notice 1999-17, Problems Associated with Post-Fire Safe-Shutdown Circuit Analyses (3 June 1999, Topic: Hot Short, Safe Shutdown, Temporary Modification, Emergency Lighting, Fire Protection Program)
- Information Notice 1999-18, Update on Nrc'S Year 2000 Activities for Material Licensees and Fuel Cycle Licensees and Certificate Holders (14 June 1999, Topic: Brachytherapy)
- Information Notice 1999-19, Rupture of the Shell Side of a Feedwater Heater at the Point Beach Nuclear Plant (23 June 1999)
- Information Notice 1999-20, Contingency Planning for the Year 2000 Computer Problem (25 June 1999, Topic: Brachytherapy)
- Information Notice 1999-21, Recent Plant Events Caused by Human Performance Errors (25 June 1999, Topic: Probabilistic Risk Assessment)
- Information Notice 1999-22, 10CFR 34.43(a)(1); Effective Date for Radiographer Certification and Plans for Enforcement Discretion (25 June 1999, Topic: Enforcement Discretion, Brachytherapy)
- Information Notice 1999-23, Safety Concerns Related to Repeated Control Unit Failures of the Nucletron Classic Model High-Dose-Rate Remote Afterloading Brachytherapy Devices (6 July 1999, Topic: Enforcement Discretion, Brachytherapy)
- Information Notice 1999-24, Broad-Scope Licensees' Responsibilities for Reviewing and Approving Unregistered Sealed Sources and Devices (12 July 1999, Topic: Enforcement Discretion, Brachytherapy)
- Information Notice 1999-25, Year 2000 Contingency Planning Activities (10 August 1999, Topic: Enforcement Discretion, Brachytherapy)
- Information Notice 1999-26, Safety and Economic Consequences of Misleading Marketing Information (24 August 1999, Topic: Enforcement Discretion, Brachytherapy)
- Information Notice 1999-27, Malfunction of Source Retraction Mechanism in Cobalt-60 Teletherapy Treatment Units (2 September 1999, Topic: Enforcement Discretion, Brachytherapy)
- Information Notice 1999-28, Recall of Star Brand Fire Protection Sprinkler Heads (30 September 1999, Topic: Enforcement Discretion, Brachytherapy)
- Information Notice 1999-30, Failure of Double Contingency Based on Administrative Controls Involving Laboratory Sampling and Spectroscopic Analysis of Wet Uranium Waste (8 November 1999, Topic: Enforcement Discretion, Brachytherapy)
- Information Notice 1999-30, Failure of Double Contingency Based On Administrative Controls Involving Laboratory Sampling and Spectroscopic Analysis of Wet Uranium Waste (8 November 1999, Topic: Enforcement Discretion, Brachytherapy)
- Information Notice 1999-31, Operational Controls to Guard Against Inadventent Nuclear Criticality (17 November 1999, Topic: Enforcement Discretion, Brachytherapy)
- Information Notice 1999-31, Operational Controls To Guard Against Inadventent Nuclear Criticality (17 November 1999, Topic: Enforcement Discretion, Brachytherapy)
- Information Notice 1999-32, Effect of Year 2000 Issue on Medical Licenseess (17 December 1999, Topic: Brachytherapy)
- Information Notice 1999-32, Effect of Year 2000 Issue on Medical Licensees (17 December 1999, Topic: Brachytherapy, Overdose, Underdose)
- Information Notice 1999-33, Management Of Wastess Contaminated with Radioactive Materialss (21 December 1999, Topic: Brachytherapy)
- Information Notice 1999-33, Management of Wastes Contaminated with Radioactive Materials (21 December 1999, Topic: Brachytherapy)
- Information Notice 1999-33, Management Of Wastes Contaminated with Radioactive Materials (21 December 1999, Topic: Brachytherapy)
- Information Notice 1999-33, Management Of Wastes Contaminated With Radioactive Materials (21 December 1999, Topic: Brachytherapy)
- Information Notice 1999-34, Potential Fire Hazard in the Use of Polyalphaolefin in Testing of Air Filter (28 December 1999)
- Information Notice 1999-34, PotentialPotentialPotential FireFireFire HazardHazardHazard ininIn thetheThe UseUseUse ofofOf PolyalphaolefinPolyalphaolefinPolyalphaolefin ininIn TestingTestingTesting ofofOf AirAirAir FilterFilterFilter (28 December 1999)
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