Information Notice 1989-35, Loss & Theft of Unsecured Licensed Material, Attachment 1 to NRC Information Notice 1990-014: Accidental Disposal of Radioactive Materials. (Also Includes Attachments 2 & 3)
| ML031210590 | |
| Person / Time | |
|---|---|
| Issue date: | 03/30/1989 |
| From: | Cunningham R NRC/NMSS/IMNS |
| To: | |
| References | |
| IN-90-014 IN-89-035, NUDOCS 8903240277 | |
| Download: ML031210590 (6) | |
Attachment 1 IN 90-14 March 6, 1990
UNITED STATES NUCLEAR REGULATORY COMMISSION
OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS
WASHINGTON, D.C. 20555 March 30, 1989 NRC INFORNATION NOTICE NO. 89-35: LOSS AND THEFT OF UNSECURED LICENSED
'AATERIAL
Addressees
All U.S. Nuclear Regulatory Commission (NRC) byproduct, source and special
nuclear material licensees.
Purpose
This notice is intended to alert recipients to the circumstances leading to
loss of licensed materials at several licensed institutions. It is expected
that licensees will review this information for applicability to their own
procedures for controlling access to licensed materials, distribute the notice
to members of the radiation safety staff, and consider actions, ifappropriate, to preclude similar situations from occurring at their facilities. However, suggestions contained in this notice do not constitute any new NRC requirements, and no written response is required.
Description of Circumstances
The following selected cases are used to illustrate losses and thefts of
unsecured material.
Case 1: In November 1988, a hospital received a one-curie gadolinium-153 sealed source for installation into a diagnostic device. The device con- taining the source was temporarily stored in the hospital's nuclear medicine
laboratory. When the technician returned on another day to retrieve and
install the sealed source, the sealed source and its shipping container
were missing. Subsequent investigation revealed that the nuclear medicine
laboratory was frequently left unlocked and unsecured during the day. In
addition, housekeeping staff who had keys to the nuclear medicine laboratory
had not been given specific instructions on recognition of radioactive materials
in storage or the precautions to take when entering areas where radioactive
materials were stored. The sealed source was never found. The hospital's
corrective actions included the installation of automatic door closers and
push button locks for daytime control, and separate key-controlled locks for
off-hour access, with keys issued to a limited number of nuclear medicine
department personnel. Further, housekeeping staff members were trained to
recognize radiation postings and shipping labels and instructed in actions
to take when containers or packages bearing these labels were encountered.
8903240277
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IN 89-35 March 30, 1989 Case 2: In August 1988, a nuclear medicine technologist at another hospital
discovered that an older set of dose calibrator reference sources had been
substituted for the current, higher-activity reference sources. Investigation
revealed that the missing reference sources had been stored in a routinely
locked nuclear medicine laboratory, and that the substituted reference sources
had been stored in a separate locked area. Further investigation revealed a
large staff turnover in the preceding year, and no firm policy for key return
by the hospital. Corrective actions included immediately changing locks and
establishing a policy that an employee's final paycheck would be withheld until
all keys were returned or accounted for. The sources in question were never
found.
Case 3: In May 1988, there were two cases where radioactive material at an
academic research laboratory had been inadvertently placed in normal trash, and subsequently buried in a municipal sanitary landfill. In the first
instance, 500 microcuries of phosphorus-32 that had been delivered to a
research laboratory was discarded to normal trash. In the second instance, less than one microcurie each of tritium, carbon-14, and iodine-125 were
removed from a research laboratory by a custodian and placed in clean trash
and also ended up in a sanitary landfill. Because these examples were
repetitive violations from a previous inspection, NRC assessed a civil
penalty of $1,125 against the licensee.
Case 4: In July 1988, the radiation safety staff at yet another institution
determined that a 0.8-millicurie cesium-137 sealed source was missing during
an inventory of sealed sources. The source had last been seen when the manu- facturer's service engineers had undertaken maintenance of a Positron Emission
Tomograhy (PET) imaging device. Despite extensive inquiries, searches, and
widespread publicity in the local community, and within the hospital, the sealed
source was never found. NRC inspections prompted certain corrective actions, such as the adoption of a policy requiring individuals to sign for radioactive
sources taken from storage and to assume personal responsibility for their
return.
Case 5: In July 1988, a researcher at the same institution as in Case 4 above
left a package containing 10 millicuries of sulfur-35 in an unsecured storage
area generally accessible to any person in the research building. The radio- active material disappeared and was never found. Corrective actions included
retraining and notifying principal investigators of their responsibilities for
radioactive material in their possession, and developing an extensive training
program for housekeeping staff members on how to recognize radiation postings
and shipping labels, and what to do if containers or packages bearing these
labels were encountered.
Case 6: In May 1988, an industrial licensee lost a moisture-density gauge
containing 40 millicuries of americium-241 and 8.3 millicuries of cesium-137.
The gauge had been loaded into a pickup truck. It is believed that the loss
occurred when the truck tailgate fell open, and the bottom of the transport
Attachment 1 IN 90-14 March 6, 1990 IN 89-35 March 30, 1989 case and gauge came apart from the top of the case. A part of the transport
case was found at the intersection of two roads. The licensee's radiation
safety officer notified NRC, the County Sheriff's Department, and the State
Department of Emergency Services and Transportation. Sixty to one-hundred
people were searching the area by nightfall. The licensee also notified
the local TV and radio stations and local newspaper. The County Sheriff's
Department found the gauge the following day about five miles from where it
was believed to be lost.
NRC considered escalated enforcement action and a civil penalty for this case, but determined that it was not warranted because the licensee took immediate
and exemplary action in reporting the event, attempting to determine the where- abouts of the lost gauge, and in implementing corrective actions to prevent
recurrence.
Case 7: While processing a request for termination of activities in November
1988, NRC learned that the licensee had improperly conveyed ownership of two
nuclear weigh scales, containing about 200 millicuries of cesium-137 each, to
a non-licensee, in February 1988. Afterwards, the licensee relinquished respon- sibility for, and control of, the material. The non-licensee acknowledged that
the nuclear devices were part of a purchase agreement, but denied ever taking
physical possession of the devices. Though both parties denied any knowledge
of what actually happened to the devices, it is apparent that the nuclear weigh
scales were dispositioned in some unknown manner during this period and are cur- rently missing. NRC and the licensee have performed extensive radiological
surveys, searches, and inquiries regarding the possible disposition of these
devices. To date, all efforts to locate the devices or the installed radio- active sources have been unsuccessful.
Discussion:
All licensees are reminded of the importance of assuring that access to
licensed radioactive material is controlled. The theft or loss of licensed
radioactive material has the potential for causing unnecessary exposures of
employees and members of the public. For example, sealed sources in Mexico
and Brazil which were not properly stored and accounted for caused life- threatening exposures of individuals, and widespread contamination of property.
In other cases, lost sources have been hidden under beds, carried in pockets, etc., resulting in the unnecessary exposure of these individuals.
Title 10, Code of Federal Regulations, Part 19, Section 19.12, OInstructions
to workers requires that all individuals working in or frequenting any portion
of a restricted area shall be kept informed of the storage, transfer, or use
of radioactive materials....'. Section 20.207 of 10 CFR Part 20, Storage and
Control of Licensed Material in Unrestricted Areas", requires that such material
be secured from unauthorized removal, and that materials not in storage in an
unrestricted area be under the constant surveillance and immediate control of
the licensee.
Attachment 1 IN 90-14 March 6, 1990 IN 89-35 March 30, 1989 Control of access to restricted areas must be sufficient to prevent in- advertent entry by unauthorized or unescorted individuals. Training of
ancillary personnel authorized for controlled access to restricted areas
should be reviewed to assure that the training is sufficient to permit
personnel to identify radioactive materials and to take appropriate pre- cautions. If activities require that licensed materials be used or stored
in unrestricted areas, licensees are required to maintain immediate control
and constant surveillance of the materials or to secure the materials against
unauthorized removal. In addition, licensees should review systems for key
control, locking of rooms, and internal transfers of licensed material, to
assure they are also effective enough to prevent unauthorized removal of the
material.
No written response is required by this information notice. If you have any
questions about this matter, please contact the appropriate regional office
or this office.
Richard E. Cunningham, Director
Division of Industrial and
Medical Nuclear Safety
Office of Nuclear Material Safety
and Safeguards
Technical Contact:
Jack Metzger, NMSS
(301) 492-3424
.Attachments:
1. List of Recently Issued N14SS Information Notices
2. List of Recently Issued NRC Information Notices
Attachment 1 IN 90-14 March 6, 1990 Attachment 2 IN 90-14 March 6, 1990 LIST OF RECENTLY ISSUED
NMSS INFORMATION NOTICES
Information - Date of
Notice No. Subject Issuance Issued to
90-09 Extended Interim Storage of 02/05/90 All holders of NRC
Low-Level Radioactive Waste materials licenses.
by Fuel Cycle and Materials
Licensees.
90-01* Importance of Proper 01/12/90 All holders of NRC
Response to Self-Identified materials licenses.
Violations by Licensees
89-85 EPA's Interim Final Rule 12/15/89 All medical, academic, on Medical Waste Tracking industrial, waste
and Management broker, and waste
disposal site licensees.
89-82 Recent Safety-Related 12/07/89 All U.S. NRC licensees
Incidents at Large authorized to possess
Irradiators and use sealed sources
at large irradiators.
89-78 Failure of Packing Nuts on 11/22/89 All U.S. NRC licensees
One-Inch Uranium Hexafluoride authorized to possess
Cylinder Valves and use source material
and/or special nuclear
material for the heating, emptying, filling, or
shipping of uranium
hexafluoride in 30- and
48-inch diameter cylinders.
89-60 Maintenance of Teletherapy 08/18/89 All U.S. NRC Medical
Units Teletherapy Licensees.
89-47 Potential Problems with 05/18/89 All holders of operating
Worn or Distorted Hose licenses or construction
Clamps on Self-Contained permits for nuclear power
Breathing Apparatus reactors and fuel
facilities.
- Correct Number for 90-01 should e 90010145
Attachment 3 IN 90-14 March 6, 1990 LIST OF RECENTLY ISSUED
NRC INFORMATION NOTICES
Information Date of
Notice No. Subject Issuance Issued to
90-13 Importance of Review and 3/5/90 All holders of OLs
Analysis of Safeguards or CPs for nuclear
Event Logs power reactors.
90-12 Monitoring or Interruption 2/28/90 All holders of OLs
of Plant Communications or CPs for nuclear
power reactors.
90-11 Maintenance Deficiency 2/28/90 All holders of OLs
Associated with Solenoid- or CPs for nuclear
Operated Valves power reactors.
90-10 Primary Water Stress 2/23/90 All holders of OLs
Corrosion Cracking (PWSCC) or CPs for PWRs.
of Inconel 600
90-09 Extended Interim Storage of 2/5/90 All holders of NRC
Low-Level Radioactive Waste materials licenses.
by Fuel Cycle and Materials
Licensees
88-30, Target Rock Two-Stage SRV 2/2/90 All holders of OLs
Supp. 1 Setpoint Drift Update or CPs for nuclear
power reactors.
90-08 Kr-85 Hazards from Decayed 2/1/90 All holders of OLs
Fuel or CPs for nuclear
power reactors and
holders of licenses
for permanently shut- down facilities with
fuel on site.
88-23, Potential for Gas Binding 1/31/90 All holders of OLs
Supp. 2 of High-Pressure Safety or CPs for PWRs.
Injection Pumps During a
Loss-of-Coolant Accident
OL = Operating License
CP = Construction Permit