United States Nuclear Regulatory Commission - Protecting People and the Environment

Information Notice No. 88-07: Inadvertent Transfer of Licensed Material to Uncontrolled Locations

                                  UNITED STATES
                          NUCLEAR REGULATORY COMMISSION
                OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS
                                WASHINGTON, D.C.  20555

                                  March 7, 1988


Information Notice No. 88-07:  INADVERTENT TRANSFER OF LICENSED MATERIAL 
                                   TO UNCONTROLLED LOCATIONS


Addressees:

All NRC broad licensees and licensees authorized to possess byproduct material 
as sealed sources in teletherapy units or "self-contained" irradiators.

Purpose:

This information notice is being issued to alert licensees of the need to 
exercise proper control over radioactive material, and to avoid inadvertent 
transfer of licensed material to uncontrolled locations or to unauthorized 
recipients.  The NRC is particularly concerned about large sources such as 
those used in teletherapy units and irradiators.  It is expected that 
licensees will review this information for applicability to their licensed 
activities, distribute the notice to responsible radiation safety staff, and 
consider actions, if appropriate, to prevent similar problems from occurring 
at their facilities.  However, this information notice does not constitute new 
NRC requirements, and no written response is required.

Description of Circumstances:

A cesium-137 teletherapy unit in Brazil was abandoned in a building which once 
housed a clinic.  Someone removed the teletherapy unit for its scrap metal 
value.  While dismantling the unit, the salvagers ruptured the sealed source 
capsule and spread cesium-137 (as cesium chloride powder) over a large portion 
of a city in central Brazil.

The cesium chloride powder had an attractive color, and the salvagers shared 
the powder with friends and relatives.  To date, four persons have died from 
radiation overexposures, and a number of persons are under medical 
surveillance. Several countries, including the United States, have assisted 
the Brazilian government in radiation monitoring, decontamination, and 
treatment of injured personnel.

Discussion:

The Brazilian incident illustrates the serious consequences which can result 
from failure to properly control radioactive material.  Events involving loss 
or theft of radioactive material also occur frequently in the United States, 
although the events have been less serious in nature.  The Commission is con-
cerned that licensees might not, in all cases, be exercising proper management


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                                                            March 7, 1988
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oversight to avoid such incidents.  The NRC staff is currently considering 
whether additional regulatory requirements should be developed in order to 
reduce the risk of loss of hazardous radioactive material.

In the meantime, it is suggested that licensees review their licensed 
programs, license, and applicable regulations in order to assure that all 
radioactive material is accounted for, and to determine whether adequate 
precautions are in place to prevent unauthorized access, theft, or loss.  In 
particular, licensees should note the following:

     1.   Title 10 CFR Part 20 contains several requirements regarding posting 
          of radiation areas, labeling of radioactive material containers, and 
          restriction of access to radioactive material.

     2.   Most licensees are required by regulation or license condition to 
          periodically inventory or leak test sealed sources at intervals of 
          three months or six months.

     3.   Section 30.51 requires licensees to maintain records of receipt, 
          transfer, and disposal of all licensed material.

     4.   Placing surplus radioactive material into long-term storage, when 
          there is not an anticipated future need for the material, may even-
          tually result in loss of the material, or access to it by persons 
          not knowledgeable of proper precautions.  If this happens, high 
          levels of radiation exposure and widespread contamination could 
          occur.  Therefore, NRC considers that long-term storage of surplus 
          radioactive material is undesirable.  While NRC regulations do not 
          require licensees to promptly dispose of unused radioactive 
          material, licensee management may want to consider disposition 
          through disposal at a licensed burial site, or transfer to another 
          authorized licensee who would have a current need for it.

Violations of NRC requirements involving the failure to control or account for 
licensed material, especially if the failure results in loss or theft, will be 
considered for escalated enforcement action.

No written response is required by this notice.  If you have any questions 
about this matter, please contact the appropriate NRC 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 R. Metzger, NMSS
                    (301) 492-3424

Attachment:    List of Recently Issued NRC Information Notices
.                                                            Attachment
                                                            IN 88-07
                                                            March 7, 1988
                                                            Page 1 of 1

                             LIST OF RECENTLY ISSUED
                             NRC INFORMATION NOTICES
                                                                             
Information                                  Date of
Notice No.     Subject                       Issuance       Issued to       

88-06          Foreign Objects in Steam  2/29/88            All holders of OLs 
               Generators                                   or CPs for PWRs.

88-05          Fire in Annunciator Control    2/11/88       All holders of OLs
               Cabinets                                     or CPs for nuclear 
                                                            power reactors.

88-04          Inadequate Qualification      2/5/88         All holders of OLs
               and Documentation of Fire                    or CPs for nuclear
               Barrier Penetration Seals                    power reactors.

88-03          Cracks in Shroud Support      2/2/88         All holders of OLs
               Access Hole Cover Welds                      or CPs for BWRs.

88-02          Lost or Stolen Gauges         2/2/88         All NRC licensees
                                                            authorized to 
                                                            possess gauges 
                                                            under a specific 
                                                            or general 
                                                            license.

88-01          Safety Injection Pipe          1/27/88       All holders of OLs
               Failure                                      or CPs for nuclear
                                                            power reactors.

86-81,         Broken External Closure        1/11/88       All holders of OLs
Supp. 1        Springs on Atwood & Morrill                  or CPs for nuclear
               Main Steam Isolation Valves                  power reactors.

87-67          Lessons Learned from           12/31/87      All holders of OLs
               Regional Inspections of                      or CPs for nuclear
               Licensee Actions in Response                 power reactors.
               to IE Bulletin 80-11

87-66          Inappropriate Application      12/31/87      All holders of OLs
               of Commercial-Grade                          or CPs for nuclear
               Components                                   power reactors.

87-28,         Air Systems Problems at        12/28/87      All holders of OLs
Supp. 1        U.S. Light Water Reactors                    or CPs for nuclear
                                                            power reactors.
                                                                             
OL = Operating License
CP = Construction Permit

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