Information Notice No. 85-57: Lost Iridium-192 Source Resulting in the Death of Eight Persons in Morocco

                                                           SSINS No.: 6835 
                                                            IN 85-57       

                                UNITED STATES
                        NUCLEAR REGULATORY COMMISSION
                    OFFICE OF INSPECTION AND ENFORCEMENT
                           WASHINGTON, D.C. 20555

                                July 16, 1985

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. 
Subsequently, the guide tube was disconnected from the camera and the source
eventually 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. 



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                                                              IN 85-57     
                                                              July 16, 1985 
                                                              Page 2 of 2  

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 
                                   Division of Inspection Programs 
                                   Office of Inspection and Enforcement 

Technical Contact:  J. R. Metzger, IE
                    (301) 492-4947

                    J. O. Lubenau, SP
                    (301) 492-9887

Attachment: List of Recently Issued IE Information Notices