Information Notice No. 90-14: Accidental Disposal of Radioactive Materials

                                UNITED STATES
                           WASHINGTON, D.C.  20555

                                March 6, 1990


Addressees:    All U.S. Nuclear Regulatory Commission (NRC) Byproduct 
               Materials Licensees. 


This information notice (IN) alerts licensees to recent cases where 
unauthorized, accidental disposal of radioactive material has occurred, and 
of the need to avoid storing radioactive materials in places where the 
materials could inadvertently be disposed of in an unauthorized manner 
(e.g., unauthorized land burial, incineration, or removal to unrestricted 
areas).  Licensees should review this information for applicability to their 
programs, distribute it to appropriate personnel and consider actions, as 
appropriate, to preclude these events from occurring at their facilities.  
Information contained in this notice does not constitute new NRC 

Description of Circumstances: 

Licensees were previously informed of the importance of assuring that access 
to licensed radioactive material is controlled (IN 89-35, "Loss and Theft of 
Unsecured Licensed Material," attached.)  The following additional cases are 
examples of events that have occurred since IN 89-35 was issued. 

CASE 1.  Accidental Incineration of Iodine-131 

A licensee reported that radioactive trash containing approximately 1 
millicurie of iodine-131 (used for a medical procedure) was removed from a 
hospital patient's room and incinerated with non-radioactive waste.  A 
follow-up inspection determined that the incinerated material was 
iodine-131, and that there was a lack of proper training among licensee 

CASE 2. Incineration of Iodine-125 Brachytherapy Seeds 

A licensee's Radiation Safety Officer informed the NRC of the apparent loss 
of control of four iodine-125 seeds, approximately one millicurie of 
activity each.  Twenty seeds had been implanted in a patient in a hospital 
operating room during a cancer treatment.  The surgical materials, 
coverings, and waste materials were not surveyed, but were put in the 
infectious waste trash. 


                                                            IN 90-14 
                                                            March 6, 1990 
                                                            Page 2 of 3 

Later, x-rays were taken of the patient's implant site, revealing that only 
16 of the 20 seeds were in place.  The licensee concluded that the four 
seeds were incinerated.  The manufacturer of the seeds stated that intense 
heat from burning would break down the titanium capsule that covered the 

CASE 3. Loss of Two Industrial Gauges Containing Strontium-90 Sources 

A licensee reported that two density measurement gauges had been 
inadvertently transferred from its facility to a scrap metal processor.  
Searches at the scrap dealer failed to locate the devices.  The gauges each 
contained a 13-millicurie strontium-90 sealed source.  One gauge was 
subsequently located by NRC inspectors.  NRC imposed a civil penalty for the 
first lost source, and licensee is still looking for the remaining source. 

CASE 4.  Loss of a 40-Microcurie Cesium-137 Sealed Source 

A licensee reported the loss of a 40 microcurie cesium-137 sealed reference 
source (part of a liquid scintillation counter) that had been sent 
inadvertently to a scrap-yard for disposal.  The source has not been found. 

CASE 5.  Lost Density Level Gauge 

A licensee informed an NRC regional office that it was unable to locate a 
generally licensed density gauge, which it previously possessed, despite an 
on-going intensive search.  The gauge contained 50 millicuries of 
cesium-137, and has not been found. 

CASE 6.  Steel Furnace Melts Cesium Source 

An Agreement State notified the NRC that a cesium-137 source had been 
inadvertently melted by a steel mill.  The mill reported to the State that 
an outgoing rail shipment of furnace flue dust tripped the plant's radiation 
monitors.  Surveys by a consultant and by a State inspector found radiation 
levels up to 1 mr/hr on the sides of the railcars.  Analysis of samples 
identified the contaminant as cesium-137.  

The NRC is aware of 15 cases, since 1983, of accidental smelting of 
radioactive sources.  Eleven have occurred in the United States.  Cesium-137 
and cobalt-60 are the primary sources of contamination.  In response, many 
scrapyards and dealers have installed radiation detectors to monitor 
incoming scrap.  In 1986, NRC issued a hazardous scrap warning poster that 
has been distributed to the ferrous and non-ferrous metal industry. 


IN 89-35, "Loss and Theft of Unsecured Licensed Material", issued in March, 
1989, reminded licensees of the importance of assuring that access to 
licensed radioactive material is controlled.  This notice cites recent 
examples of loss of radioactive materials, and indicates that many licensees 
did not take sufficient actions to address this problem when IN 89-35 was 


                                                            IN 90-14 
                                                            March 6, 1990 
                                                            Page 3 of 3 

Licensees should review systems for control of licensed material and 
routinely instruct employees in the actions needed to assure control of 
licensed material.  Particular attention should be paid to instructing 
workers who may only come in contact with licensed material on an occasional 
basis, since several of the cited losses were due, in part, to the failure 
of employees to recognize or appropriately handle licensed material. 

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 materials 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. 

Licensees are reminded of the importance of ensuring that access to licensed 
radioactive material is controlled as required by NRC regulations.  The 
incineration, burial, or damage of licensed radioactive material has the 
potential for causing unnecessary exposures of employees and members of the 
public.  Severe penalties can be imposed for failure to control access to 
licensed material as required by the NRC regulations.  It is suggested that 
licensees review their programs to assure that all radioactive material is 
properly secured against unauthorized removal, and that workers are properly 
trained in proper safety procedures. 

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, NMSS

Technical Contact:  Jack R. Metzger, NMSS
                    (301) 492-3424

1.  IN 89-35, Loss and Theft of
      Unsecured Licensed Material
2.  List of Recently Issued NMSS Information Notices
3.  List of Recently Issued NRC Information Notices

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