Information Notice 1999-23, Safety Concerns Related to Repeated Control Unit Failures of the Nucletron Classic Model High-Dose-Rate Remote Afterloading Brachytherapy Devices: Difference between revisions
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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 | :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 | ||
'-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 representativ 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.gov | '-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 representativ 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.gov | ||
===Attachments:=== | ===Attachments:=== | ||
1. List of Recently Issued NMSS Information Notices2. List of Recently Issued NRC Information NoticesItWt4 a,-TV 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) | 1. List of Recently Issued NMSS Information Notices2. List of Recently Issued NRC Information NoticesItWt4 a,-TV 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) | ||
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 | 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 | ||
<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.gov | <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.gov | ||
===Attachments:=== | ===Attachments:=== | ||
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 IN 99-XXAJ June XX, 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.gov | 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 IN 99-XXAJ June XX, 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.gov | ||
===/Attachments:=== | ===/Attachments:=== | ||
1. List of Recently Issued NMSS Information Notices2. List of Recently Issued NRC Information Notices A''<//DOCUMENT NAME: A & G:\AYRES\IN99C-XX.WPD* See previous concurrenceOFFICE MSIB I C Editor I MSIB* I lISIB l MSIB I NNAME RAyrestic EKraus FSturz LCamper DC_______DATE 6/ 09 /99 6/09 /99 6/15/99 6/15/99 6/.t1/99OFFICIAL RECORD COPY | 1. List of Recently Issued NMSS Information Notices2. List of Recently Issued NRC Information Notices A''<//DOCUMENT NAME: A & G:\AYRES\IN99C-XX.WPD* See previous concurrenceOFFICE MSIB I C Editor I MSIB* I lISIB l MSIB I NNAME RAyrestic EKraus FSturz LCamper DC_______DATE 6/ 09 /99 6/09 /99 6/15/99 6/15/99 6/.t1/99OFFICIAL RECORD COPY | ||
.z~ IN 99-XXJune xx, 1999 }} | .z~ IN 99-XXJune xx, 1999 }} | ||
{{Information notice-Nav}} | {{Information notice-Nav}} | ||
Revision as of 16:40, 4 March 2018
July 6, 1999
NRC INFORMATION NOTICE 99-23: SAFETY CONCERNS RELATED TO REPEATEDCONTROL UNIT FAILURES OF THE NUCLETRONCLASSIC MODEL HIGH-DOSE-RATE REMOTEAFTERLOADING BRACHYTHERAPY DEVICES
Addressees
- All U.S. Nuclear Regulatory Commission (NRC) medical licensees authorized to usebrachytherapy sources in Nucletron Classic Model high-dose-rate (HDR) remote afterloaders.
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.
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
'-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 representativ 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.gov
Attachments:
1. List of Recently Issued NMSS Information Notices2. List of Recently Issued NRC Information NoticesItWt4 a,-TV 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)
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
<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.gov
Attachments:
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 IN 99-XXAJ June XX, 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.gov
/Attachments:
1. List of Recently Issued NMSS Information Notices2. List of Recently Issued NRC Information Notices A<//DOCUMENT NAME: A & G:\AYRES\IN99C-XX.WPD* See previous concurrenceOFFICE MSIB I C Editor I MSIB* I lISIB l MSIB I NNAME RAyrestic EKraus FSturz LCamper DC_______DATE 6/ 09 /99 6/09 /99 6/15/99 6/15/99 6/.t1/99OFFICIAL RECORD COPY
.z~ IN 99-XXJune xx, 1999