Information Notice 1985-57, Lost Iridium-192 Source Resulting in the Death of Eight Persons in Morocco

Lost Iridium-192 Source Resulting in the Death of Eight Persons in Morocco

ML031180188
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, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Skagit, Marble Hill
Issue date:	07/16/1985
From:	Partlow J NRC/OE
To:
References
IN-85-057, NUDOCS 8507120312
Download: ML031180188 (3)

SSINS No.: 6835 IN 85-57 UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF INSPECTION AND ENFORCEMENT

WASHINGTON, D.C. 20555 July 16, 1985 IE INFORMATION NOTICE NO. 85-57: LOST IRIDIUM-192 SOURCE RESULTING IN THE

DEATH OF EIGHT PERSONS IN MOROCCO

Addressees

All licensees that possess, use, and manufacture radiographic exposure devices

with sealed radiation sources.

Purpose

This information notice is provided to alert recipients of a serious safety

problem when radiography sources are not controlled by surveillance and when

radiological surveys are not performed to make certain that such sources are

under control at all times.

It is expected that licensees will review this notice for applicability to their

radiographic activities, if appropriate, to preclude-a potential of serious over- exposures to individuals. However, suggestions contained in this information

notice do not constitute NRC requirements; therefore, no specific action or

written response is required.

Description of Circumstances

In March 1984, a serious radiation incident occurred in Morocco that was reported

in an official press release from the Ministry of the Interior. In the course

of this accident, eight persons died from overexposure to radiation. Other

individuals also received significant doses of radiation that required medical

attention. Three individuals who were severely injured were hospitalized at

the Curie Institute in Paris and later were released in apparently satisfactory

condition after medical treatment.

The accident originated at a fossil-fueled power plant under construction in

Mohammedia, Morocco, where iridium-192 sources were being used to radiograph

welds. In March 1984, one of these sources, that contained approximately 30

curies of iridium-192 at the time, apparently became disconnected from the

drive cable and was not properly returned to its shielded container. Sub- sequently, the guide tube was disconnected from the camera and the source even- tually dropped to the ground, where a passing laborer noticed the tiny metal

cylinder and took it home. Although it is not clearly known if the problem

originated from a disconnect between the source pigtail and drive cable or if a

break occurred between the pigtail and source, there are indications that the

latter may have occurred.

8507120312

IN 85-57 July 16, 1985 Discussion:

Within a relatively short period of time, during May and June of 1984, a total

of eight persons, including the laborer and his entire family and some relatives, died with the clinical diagnosis of "lung hemorrhages." It was initially assumed

that the deaths were the result of poisoning. Only after the last family member

had died was it suspected that the deaths might have been caused by radiation.

The source was recovered in June 1984.

Although the source container was marked by the internationally recognized

radiation caution symbol, the source itself bore no markings.

There is no information available on the precautionary radiation surveys that

may have been performed at the time of the incident. However, it is apparent from the

stated facts that radiation surveys of the type described in the NRC regulations, if performed, would have disclosed the problem and may have prevented the

incident.

No specific action or written response is required by this information notice.

If you have any questions about this matter, please contact the Regional

Administrator of the appropriate NRC regional office or this office.

James G. Partlow, Director

Divilion of Inspection Programs

Office of Inspection and Enforcement

Technical Contacts: J. R. Metzger, IE

(301) 492-4947 J. 0. Lubenau, SP

(301) 492-9887 Attachment: List of Recently Issued IE Information Notices

Attachment 1 IN 85-57 July 16, 1985 LIST OF RECENTLY ISSUED

IE INFORMATION NOTICES

Information Date of

Notice No. ' Subject Issue Issued to

85-56 Inadequate Environment .7/15/85, All power reactor

Control For Components And"-' "ficiI ities holding

Systems .InExtended.Storaige 'an OL or CPV

Or Layup'. -

85-55 Revised Emergency Exercise' 7/15/85;.. . All power reactor

Frequency Rule facilities holding

an OL or CP

85-54 Teletheraphy Unit Malfunction 7/15/85 All NRC licensees

authorized to use

teletheraphy units

85-53 Performance Of NRC-Licensed 7/12/85 All power reactor

Individuals While On Duty facilities holding

an OL or CP

85-52 Errors IrnjDosdr Assessment 7/10/85 All power reactor

Computer Codes And Reporting facilities holding

Requirements Under 10 CFR an OL or CP

Part 21

85-51 Inadvertent Loss Or Improper 7/10/85 All power reactor

Actuation Of Safety-Related facilities holding

Equipment an OL or CP

85-50 Complete Loss Of Main And 7/8/85 All power reactor

Auxiliary Feedwater At A PWR facilities holding

Designed By Babcock & Wilcox an OL or CP

85-49 Relay Calibration Problem 7/1/85 All power reactor

facilities holding

an OL or CP

85-48 Respirator Users Notice: 6/19/85 All power reactor

Defective Self-Contained facilities holding

Breathing Apparatus Air an OL or CP, research, Cylinders and test reactor, fuel cycle and

Priority 1 material

licensees

OL = Operating License

CP = Construction Permit