Information Notice No. 94-16: Recent Incidents Resulting in Offsite Contamination


March 3, 1994



All U.S. Nuclear Regulatory Commission material and fuel cycle licensees.


NRC is issuing this information notice to alert licensees of recent
contamination incidents and their root causes.  It is expected that recipients
will review the information for applicability to their facilities and consider
actions, as appropriate, to avoid similar problems.  However, information
contained in this notice does not constitute a new requirement, and no
specific action nor written response is required.

Description of Circumstances

Recently, NRC responded to three radioactive material contamination incidents,
which resulted in contamination of both individuals and personal property,
both on and off the licensees' property, and which required access to the
contaminated areas to be restricted for more than 24 hours.  Two of the cases
summarized below occurred at large universities and one occurred at a large
medical facility.  All have resulted in escalated enforcement actions
involving fines.

Case 1: The licensee notified NRC that a contamination event involving
phosphorus-32 (P-32) had occurred at the facility, contaminating
several floors of a research building.  A graduate student, working
on the weekend, using P-32, accidentally and unknowingly
contaminated the floor of the laboratory with 3.7 to 18.5
megabecquerels (100 to 500 microcuries) of the material.  He failed
to survey himself or the laboratory before leaving, as required by
the licensee's procedures.  His actions resulted in the widespread
contamination of the laboratory building and of private residences,
clothing, and vehicles.  The licensee reported the event after it
was clear that the research building decontamination work was going
to extend beyond 24 hours, and that the facility would have to
remain restricted.  In the licensee's verbal report, it assured NRC
that the contamination was confined to the research building.  NRC
dispatched a special inspection team to the site, and in the process
of conducting confirmatory surveys, off-site contamination was
identified.  The licensee focused its efforts on the decontamination
of the laboratory, and failed to perform an adequate assessment of
possible offsite contamination.  Contributing causes of this

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contamination event were:  1) failure of a student researcher to
exercise appropriate precautions in the handling of licensed
materials; 2) failure to conduct personnel surveys; 3) inadequate
training or supervision by the authorized user; 4) failure to
conduct performance-oriented audits of the licensee's authorized
users; and 5) failure of the Radiation Safety Staff to properly
analyze and respond to the event.

Case 2:NRC became aware of a potential contamination problem and called the
licensee to determine if a problem did exist.  The licensee
confirmed that a contamination event had occurred involving carbon-14 (C-14)
in a research building, but that it was confident that no contamination had
left the building.  NRC dispatched a special inspection team to the site.
While the team was traveling to the site, the licensee discovered that the
contamination occurred because a researcher, looking for materials for an
experiment, unknowingly contaminated himself and some personal effects with
C-14.  The individual was not aware that he had handled radioactive
material because the material was improperly stored in an
unrestricted area, in an unmarked container.  Surveys conducted by
the licensee, NRC, three States, other universities, and a U.S.
Department of Energy laboratory, identified that the individual
unknowingly spread the contamination throughout the facility, to
residences he visited, to automobiles, and to his private residence.
In addition, other personnel who had entered the facility
contaminated their shoes.  Contributing causes of this contamination
event were: 1) the improper storage of the material which was
caused, in part, by 2) an inadequate inventory system that did not
identify the presence of long-lived licensed material in an
unrestricted area; 3) improper labelling; and 4) inadequate training
for staff responsible for storage.

Case 3:A contamination event occurred when a post-graduate student came
into a laboratory to do some work involving P-32, on the weekend.
He failed to survey, because of an inoperative survey meter, and
left the laboratory, having contaminated himself with P-32.  When
the contamination was discovered, the licensee focused on the
contaminated individual and the laboratory.  The licensee called to
inform NRC that it was sending a report documenting a P-32
contamination event that had occurred at the facility approximately
10 days earlier.  The licensee indicated that there had been
personnel contamination, but that no offsite contamination had
occurred.  NRC dispatched a special inspection team to the facility.
Confirmatory surveys conducted by the licensee and this team
identified offsite contamination in a church, several residences,
and in automobiles.  Contributing causes of this event were: 1) the
licensee failed to respond properly to a recognized spill; 2) the
licensee failed to perform an adequate survey of all the possible
locations where the individual had been during the interim period
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after the contamination event; 3) the licensee failed to follow
proper, established survey procedures; 4) there was inoperative
equipment; and 5) inadequate training of staff.


In the cases described above, the root cause was one or a combination of the
following:  (1) inadequate training of the employee in the handling and use of
radioactive material; (2) inadequate monitoring of persons and facilities
where material was used; and (3) inadequate management oversight of licensed

Training had been provided to the user of the material, in most cases, but it
was either inadequate or ignored.  Site-specific training should include
proper survey techniques and correct response to contamination events, and
should be strongly emphasized through retraining programs.

General requirements for monitoring are contained in 10 CFR 20.1501.  In
specific cases, licensees have not discovered the spread of contamination,
because of inadequate surveys, until days, or sometimes weeks, after the
original incident occurred.  The person using the material did not check for
personal contamination before leaving the laboratory, and routine surveys of
the area were not conducted in time to prevent widespread contamination.

Regulations also require licensed materials to be properly stored and labeled;
proper labeling could have prevented some of the above, by alerting personnel
to the existence of radioactive material and to the necessity of following
radiation safety procedures and survey requirements.

When a spill does occur, it is important that the licensee respond properly to
the event.  A rush to resume normal activities should be avoided. The lack of
sufficient technical personnel for proper offsite assessment may complicate an
already undesirable situation.  The possibility of offsite contamination
should be considered in the evaluation of a spill or contamination, and in a
subsequent decontamination plan.

In two of the cases detailed above, licensees failed to notify the NRC
Operations Center within 24 hours, as required by 10 CFR 30.50, after the
discovery of an unplanned contamination event that required access to the
contaminated area to be restricted for more than 24 hours.  The notification
requirements of 10 CFR 30.50, 40.60, and 70.50, are in addition to 10 CFR
20.2202, involving personnel exposure and releases of radioactive material.
The NRC Operations Center telephone number is (301) 951-0550; it is available
24 hours a day.

Each licensee is responsible for protecting the public health and safety by
ensuring that all NRC requirements are met, and any potential hazards are
promptly identified, corrected, and, if necessary, reported.  This
responsibility can only be fulfilled if there is persistent and adequate
management oversight of licensed activities.  .
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This information notice requires no specific action nor written response.  If
you have questions about the information in this notice, please contact the
technical contact listed below, or the appropriate regional office.

/s/'d by Carl J. Papiello

                        Carl J. Paperiello, Director
                        Division of Industrial and
                          Medical Nuclear Safety
                        Office of Nuclear Material Safety
                          and Safeguards

Technical contacts:  Roy Caniano, RIII
               (708) 829-9804

               Joseph E. DeCicco, NMSS
               (301) 504-2067

1.  List of Recently Issued NMSS Information Notices
2.  List of Recently Issued NRC Information Notices


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