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 |
| Revision: | 0 |
| From: | Cunningham R E NRC/NMSS/IMNS |
| To: | |
| References | |
| IN-90-014 IN-89-035, NUDOCS 8903240277 | |
| Download: ML031210590 (6) | |
Attachment 1IN 90-14March 6, 1990UNITED STATES NUCLEAR REGULATORY COMMISSIONOFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDSWASHINGTON, D.C. 20555March 30, 1989NRC INFORNATION NOTICE NO. 89-35: LOSS AND THEFT OF UNSECURED LICENSED'AATERIAL
Addressees
- All U.S. Nuclear Regulatory Commission (NRC) byproduct, source and specialnuclear material licensees.
Purpose
- This notice is intended to alert recipients to the circumstances leading toloss of licensed materials at several licensed institutions. It is expectedthat licensees will review this information for applicability to their ownprocedures for controlling access to licensed materials, distribute the noticeto members of the radiation safety staff, and consider actions, if appropriate,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 ofunsecured material.Case 1: In November 1988, a hospital received a one-curie gadolinium-153sealed source for installation into a diagnostic device. The device con-taining the source was temporarily stored in the hospital's nuclear medicinelaboratory. When the technician returned on another day to retrieve andinstall the sealed source, the sealed source and its shipping containerwere missing. Subsequent investigation revealed that the nuclear medicinelaboratory was frequently left unlocked and unsecured during the day. Inaddition, housekeeping staff who had keys to the nuclear medicine laboratoryhad not been given specific instructions on recognition of radioactive materialsin storage or the precautions to take when entering areas where radioactivematerials were stored. The sealed source was never found. The hospital'scorrective actions included the installation of automatic door closers andpush button locks for daytime control, and separate key-controlled locks foroff-hour access, with keys issued to a limited number of nuclear medicinedepartment personnel. Further, housekeeping staff members were trained torecognize radiation postings and shipping labels and instructed in actionsto take when containers or packages bearing these labels were encountered.8903240277
-^IN 89-35March 30, 1989 Case 2: In August 1988, a nuclear medicine technologist at another hospitaldiscovered that an older set of dose calibrator reference sources had beensubstituted for the current, higher-activity reference sources. Investigationrevealed that the missing reference sources had been stored in a routinelylocked nuclear medicine laboratory, and that the substituted reference sourceshad been stored in a separate locked area. Further investigation revealed alarge staff turnover in the preceding year, and no firm policy for key returnby the hospital. Corrective actions included immediately changing locks andestablishing a policy that an employee's final paycheck would be withheld untilall keys were returned or accounted for. The sources in question were neverfound.Case 3: In May 1988, there were two cases where radioactive material at anacademic research laboratory had been inadvertently placed in normal trash,and subsequently buried in a municipal sanitary landfill. In the firstinstance, 500 microcuries of phosphorus-32 that had been delivered to aresearch laboratory was discarded to normal trash. In the second instance,less than one microcurie each of tritium, carbon-14, and iodine-125 wereremoved from a research laboratory by a custodian and placed in clean trashand also ended up in a sanitary landfill. Because these examples wererepetitive violations from a previous inspection, NRC assessed a civilpenalty of $1,125 against the licensee.Case 4: In July 1988, the radiation safety staff at yet another institutiondetermined that a 0.8-millicurie cesium-137 sealed source was missing duringan inventory of sealed sources. The source had last been seen when the manu-facturer's service engineers had undertaken maintenance of a Positron EmissionTomograhy (PET) imaging device. Despite extensive inquiries, searches, andwidespread publicity in the local community, and within the hospital, the sealedsource was never found. NRC inspections prompted certain corrective actions,such as the adoption of a policy requiring individuals to sign for radioactivesources taken from storage and to assume personal responsibility for theirreturn.Case 5: In July 1988, a researcher at the same institution as in Case 4 aboveleft a package containing 10 millicuries of sulfur-35 in an unsecured storagearea generally accessible to any person in the research building. The radio-active material disappeared and was never found. Corrective actions includedretraining and notifying principal investigators of their responsibilities forradioactive material in their possession, and developing an extensive trainingprogram for housekeeping staff members on how to recognize radiation postingsand shipping labels, and what to do if containers or packages bearing theselabels were encountered.Case 6: In May 1988, an industrial licensee lost a moisture-density gaugecontaining 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 lossoccurred when the truck tailgate fell open, and the bottom of the transportAttachment 1IN 90-14March 6, 1990 IN 89-35March 30, 1989 case and gauge came apart from the top of the case. A part of the transportcase was found at the intersection of two roads. The licensee's radiationsafety officer notified NRC, the County Sheriff's Department, and the StateDepartment of Emergency Services and Transportation. Sixty to one-hundredpeople were searching the area by nightfall. The licensee also notifiedthe local TV and radio stations and local newspaper. The County Sheriff'sDepartment found the gauge the following day about five miles from where itwas 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 immediateand exemplary action in reporting the event, attempting to determine the where-abouts of the lost gauge, and in implementing corrective actions to preventrecurrence.Case 7: While processing a request for termination of activities in November1988, NRC learned that the licensee had improperly conveyed ownership of twonuclear weigh scales, containing about 200 millicuries of cesium-137 each, toa non-licensee, in February 1988. Afterwards, the licensee relinquished respon-sibility for, and control of, the material. The non-licensee acknowledged thatthe nuclear devices were part of a purchase agreement, but denied ever takingphysical possession of the devices. Though both parties denied any knowledgeof what actually happened to the devices, it is apparent that the nuclear weighscales were dispositioned in some unknown manner during this period and are cur-rently missing. NRC and the licensee have performed extensive radiologicalsurveys, searches, and inquiries regarding the possible disposition of thesedevices. 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 tolicensed radioactive material is controlled. The theft or loss of licensedradioactive material has the potential for causing unnecessary exposures ofemployees and members of the public. For example, sealed sources in Mexicoand 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, OInstructionsto workers requires that all individuals working in or frequenting any portionof a restricted area shall be kept informed of the storage, transfer, or useof radioactive materials....'. Section 20.207 of 10 CFR Part 20, Storage andControl of Licensed Material in Unrestricted Areas", requires that such materialbe secured from unauthorized removal, and that materials not in storage in anunrestricted area be under the constant surveillance and immediate control ofthe licensee.Attachment 1IN 90-14March 6, 1990 IN 89-35March 30, 1989 Control of access to restricted areas must be sufficient to prevent in-advertent entry by unauthorized or unescorted individuals. Training ofancillary personnel authorized for controlled access to restricted areasshould be reviewed to assure that the training is sufficient to permitpersonnel to identify radioactive materials and to take appropriate pre-cautions. If activities require that licensed materials be used or storedin unrestricted areas, licensees are required to maintain immediate controland constant surveillance of the materials or to secure the materials againstunauthorized removal. In addition, licensees should review systems for keycontrol, locking of rooms, and internal transfers of licensed material, toassure they are also effective enough to prevent unauthorized removal of thematerial.No written response is required by this information notice. If you have anyquestions about this matter, please contact the appropriate regional officeor this office.Richard E. Cunningham, DirectorDivision of Industrial andMedical Nuclear SafetyOffice of Nuclear Material Safetyand Safeguards
Technical Contact:
Jack Metzger, NMSS(301) 492-3424.
Attachments:
1. List of Recently Issued N14SS Information Notices2. List of Recently Issued NRC Information NoticesAttachment 1IN 90-14March 6, 1990 Attachment 2IN 90-14March 6, 1990 LIST OF RECENTLY ISSUEDNMSS INFORMATION NOTICESInformation -Date ofNotice No. Subject Issuance Issued to90-0990-01*89-8589-8289-7889-6089-47Extended Interim Storage ofLow-Level Radioactive Wasteby Fuel Cycle and MaterialsLicensees.Importance of ProperResponse to Self-IdentifiedViolations by LicenseesEPA's Interim Final Ruleon Medical Waste Trackingand ManagementRecent Safety-RelatedIncidents at LargeIrradiatorsFailure of Packing Nuts onOne-Inch Uranium HexafluorideCylinder ValvesMaintenance of TeletherapyUnitsPotential Problems withWorn or Distorted HoseClamps on Self-ContainedBreathing Apparatus02/05/9001/12/9012/15/8912/07/8911/22/8908/18/8905/18/89All holders of NRCmaterials licenses.All holders of NRCmaterials licenses.All medical, academic,industrial, wastebroker, and wastedisposal site licensees.All U.S. NRC licenseesauthorized to possessand use sealed sourcesat large irradiators.All U.S. NRC licenseesauthorized to possessand use source materialand/or special nuclearmaterial for the heating,emptying, filling, orshipping of uraniumhexafluoride in 30- and48-inch diameter cylinders.All U.S. NRC MedicalTeletherapy Licensees.All holders of operatinglicenses or constructionpermits for nuclear powerreactors and fuelfacilities.*Correct Number for 90-01 should e 90010145 Attachment 3IN 90-14March 6, 1990 LIST OF RECENTLY ISSUEDNRC INFORMATION NOTICESInformation Date ofNotice No. Subject Issuance Issued to90-1390-1290-1190-1090-09Importance of Review andAnalysis of SafeguardsEvent LogsMonitoring or Interruptionof Plant CommunicationsMaintenance DeficiencyAssociated with Solenoid-Operated ValvesPrimary Water StressCorrosion Cracking (PWSCC)of Inconel 600Extended Interim Storage ofLow-Level Radioactive Wasteby Fuel Cycle and MaterialsLicenseesTarget Rock Two-Stage SRVSetpoint Drift UpdateKr-85 Hazards from DecayedFuelPotential for Gas Bindingof High-Pressure SafetyInjection Pumps During aLoss-of-Coolant Accident3/5/902/28/902/28/902/23/902/5/902/2/902/1/901/31/90All holders of OLsor CPs for nuclearpower reactors.All holders of OLsor CPs for nuclearpower reactors.All holders of OLsor CPs for nuclearpower reactors.All holders of OLsor CPs for PWRs.All holders of NRCmaterials licenses.All holders of OLsor CPs for nuclearpower reactors.All holders of OLsor CPs for nuclearpower reactors andholders of licensesfor permanently shut-down facilities withfuel on site.All holders of OLsor CPs for PWRs.88-30,Supp. 190-0888-23,Supp. 2OL = Operating LicenseCP = Construction Permit