Information Notice No. 89-35: Loss and Theft of Unsecured Licensed Material

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

                                 March 30, 1989


Information Notice No. 89-35:  LOSS AND THEFT OF UNSECURED LICENSED 
                                   MATERIAL

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, 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 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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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 house-keeping 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 
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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, "Instructions 
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.  
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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 NMSS Information Notices
2.  List of Recently Issued NRC Information Notices
.                                                            Attachment 2 
                                                            IN 89-35
                                                            March 30, 1989
                                                            Page 1 of 1

                             LIST OF RECENTLY ISSUED
                             NRC INFORMATION NOTICES
_____________________________________________________________________________
Information                                  Date of 
Notice No._____Subject_______________________Issuance_______Issued to________

89-34          Disposal of Americium         3/30/89        All holders of an
               Well-Logging Sources                         NRC specific 
                                                            license 
                                                            authorizing well-
                                                            logging activities.

89-33          Potential Failure of          3/23/89        All holders of OLs
               Westinghouse Steam                           or CPs for PWRs.
               Generator Tube 
               Mechanical Plugs

89-32          Surveillance Testing          3/23/89        All holders of OLs
               of Low-Temperature                           or CPs for PWRs.
               Overpressure-Protection
               Systems

89-31          Swelling and Cracking         3/22/89        All holders of OLs
               of Hafnium Control Rods                      or CPs for PWRs 
                                                            with Hafnium 
                                                            control rods. 

89-30          High Temperature              3/15/89        All holders of OLs
               Environments at                              or CPs for nuclear
               Nuclear Power Plants                         power reactors.

89-29          Potential Failure of          3/15/89        All holders of OLs
               ASEA Brown Boveri                            or CPs for nuclear
               Circuit Breakers                             power reactors.
               During Seismic Event

89-28          Weight and Center of          3/14/89        All holders of OLs
               Gravity Discrepancies                        or CPs for nuclear
               for Copes-Vulcan                             power reactors.
               Air-Operated Valves

89-27          Limitations on the Use        3/8/89         All holders of OLs
               of Waste Forms and High                      or CPs for nuclear
               Integrity Containers for                     power reactors, 
               the Disposal of Low-Level                    fuel cycle 
               Radioactive Waste                            licenses and 
                                                            certain by-product 
                                                            materials 
                                                            licenses. 

_____________________________________________________________________________ 
OL = Operating License
CP = Construction Permit 
..