ML090370785 

UNITED STATES 

NUCLEAR REGULATORY COMMISSION 

OFFICE OF FEDERAL AND STATE MATERIALS 

AND ENVIRONMENTAL MANAGEMENT PROGRAMS 

WASHINGTON, D.C. 20555 

February 3, 2009 

NRC INFORMATION NOTICE 2009-05 CONTAMINATION EVENTS RESULTING FROM 

DAMAGE TO SEALED RADIOACTIVE SOURCES 

DURING GAUGE DISMANTLEMENT AND NONROUTINE MAINTENANCE OPERATIONS

 

ADDRESSEES 

All U.S. Nuclear Regulatory Commission (NRC) materials licensees. All Agreement State 

Radiation Control Program Directors and State Liaison Officers. 

PURPOSE

The U.S. Nuclear Regulatory Commission is issuing this Information Notice (IN) to alert 

addressees of recently reported events that occurred during gauge dismantlement or nonroutine maintenance operations that involved the handling or removal of sealed radioactive 

sources. During these events, sealed radioactive sources were damaged or ruptured, leading 

to both facility and personnel contamination. It is expected that recipients will review the 

information for applicability to their facilities and consider actions, as appropriate, to avoid 

similar incidents. However, the suggestions contained in this information notice are not new 

NRC requirements; therefore, no specific action, or written response is required. The NRC is 

providing this IN to the Agreement States for their information and for distribution to their 

licensees as appropriate. 

DESCRIPTION OF CIRCUMSTANCES

In the last three years, NRC has received five event reports, three of them recently, involving 

gauge dismantlement/disassembly or non-routine maintenance operations of devices that 

involved the handling or removal of sealed radioactive sources. Four of these events occurred 

while personnel were attempting to remove a source holder from a gauge or removing a source 

from its source holder for the purposes of source disposal. One of the events involved nonroutine maintenance of a calibration device. The specific circumstances of these events are 

discussed below. 
IN 2009-05 

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Event 1 

An NRC service provider licensee was dismantling gauges for the purpose of source removal 

and consolidation for disposal. A licensee employee attempted to dismantle a frame-type beta 

gauge containing an approximately 2.29 GBq (62 mCi) strontium-90/yttrium-90 source. The 

gauge was over 20 years old and had been in storage at the licensee’s facility for over 5 years. 

The employee performing the dismantlement had not previously worked with the particular type 

of gauge or radioactive source. The employee removed the source holder from the gauge and 

then attempted to remove the radioactive source from its source holder. The strontium-90/ 

yttrium-90 source, designed to emit beta particles, had a 0.076 mm (0.003 inch) stainless steel 

window. A leak test performed prior to dismantlement did not reveal the presence of removable 

contamination. In an attempt to remove the radioactive source from its holder, the employee 

physically impacted the source window with a screwdriver and also impacted the source holder 

containing the source onto an unyielding metal surface. Following these actions, an in-process 

leak test revealed the presence of large amounts of removable contamination. 

As a result of the damage to the source, the employee performing the dismantlement activities 

had considerable external contamination, including on the hands, face, and clothing. During onscene personnel decontamination activities, it was found that the employee also received an 

intake of strontium-90, as evidenced by the detection of radiation inside the nostrils. Three 

other licensee employees were externally contaminated to a lesser extent. The employees 

decontaminated themselves prior to leaving the licensee’s facility. The employee performing 

the dismantlement was taken to a local health care facility for medical evaluation as a 

precautionary measure and provided several days of urine and fecal samples for bioassay 

analysis. The other three employees provided urine samples for bioassay analysis. The dose 

assessment for the employee performing the dismantlement revealed a total effective dose 

equivalent of 14.4 mSv (1.44 rem). The radiation doses to the other three employees were 

considerably lower. The licensee’s facility was extensively contaminated and strontium-90/ 

yttrium-90 was found to be dispersed widely throughout the interior of the licensee’s facility, 

considerably beyond the area where the disassembly had been performed or where 

contaminated individuals had walked within the facility. Decontamination activities were 

performed by an appropriately licensed contractor and were completed three months after the 

event. 

Event 2

During disassembly operations at the facilities of an Agreement State gauge manufacturer and 

distributor licensee, an employee attempted to remove a radioactive source from its source 

housing for the purpose of disposal. The industrial density/level fixed-type gauge had originally 

been manufactured by the licensee over 30 years prior and at the time of the incident contained 

an 11.1 GBq (300 mCi) cesium-137 sealed source. The source was damaged or breached as a 

result of an employee’s attempt to remove it from the gauge housing using a saw. Prior to 

commencing the dismantlement activities, the employee was unaware that the gauge internals 

had been custom-configured. Therefore, when the gauge was cut open with the saw, the 

sealed radioactive source was not in the area where the employee expected, and as a result, 

the radioactive source itself was damaged by the saw.
IN 2009-05 

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As a result of the damage to the source, cesium-137 was dispersed throughout the licensee’s 

source disposal room, contaminating the area with microspheres. Emergency procedures were 

activated by the licensee, and no contamination was detected on the floor outside the source 

disposal room. The employee that damaged the source exhibited contamination on one hand 

and one leg; a second employee exhibited contamination on both hands and clothing. The 

employees were decontaminated onsite and sent for medical evaluation as a precautionary 

measure. The two employees provided urine samples for bioassay analysis and also 

underwent lung counting. Calculated doses for the two employees were less than 50 uSv 

(5 mrem). Decontamination activities were performed by an appropriately licensed contractor 

and were completed two months after the event. 

Event 3

During disassembly operations at an Agreement State gauge manufacturer and distributor 

licensee, radioactive sources in two different continuous level fixed-type gauges were breached 

on the same day, resulting in personnel and facility contamination. In the first incident, a 

0.41 GBq (11 mCi) cesium-137 sealed source in a gauge was breached when an employee cut 

into the source with a band saw. In the second incident, a 0.96 GBq (26 mCi) cesium-137 

sealed source in a gauge was breached when the same employee, using a drill, broke the drill 

bit when it became stuck in the source capsule. In both cases, the employee that was 

dismantling the gauges did not have a clear understanding of the location of the sources within 

the gauges. 

Radioactive contamination was detected on the employee, throughout the source handling area, 

and in other portions of the licensee’s restricted area, including the gauge manufacturing area. 

The employee involved in the incidents was decontaminated onsite although some 

contamination remained on the fingertips. The employee was sent for medical evaluation as a 

precautionary measure. Contamination on the employee’s hands, arms, hair, and clothing was 

estimated to be 0.37 GBq (10 mCi). Urine samples from the employee were collected for 

bioassay analysis. Whole body counting of the employee was also performed. Calculations 

indicated a committed effective dose equivalent (CEDE) to the employee ranging from 21.3 to 

19.4 uSv (2.13 to 1.94 mrem). The licensee’s facility was decontaminated by an appropriately 

licensed contractor. 

Event 4

An employee of an Agreement State manufacturer and distributor licensee attempted to remove 

an approximately 12 GBq (325 mCi) cesium-137 sealed source from the source housing of a 

density/level fixed-type gauge. At the time of the event, the gauge was approximately 19 years 

old. Previous attempts had been made to remove the source from the gauge but were 

unsuccessful. The employee then attempted to gain access to the source by drilling next to 

where the source was believed to be located. However, the drill nicked and damaged the 

radioactive source. 

As a result of the damage to the source, radioactive material was dispersed in the licensee’s 

facility, contaminating the immediate work area. The licensee estimated that less than 

0.37 MBq (10 uCi) of cesium-137 was dispersed, contaminating various surfaces, including the 
IN 2009-05 

Page 4 of 6 

drill press, work bench, and floor. The licensee’s facility was decontaminated. The highest 

radiation dose to an individual was calculated by the licensee to be 10.9 mSv (1.09 rem). 

Event 5

An employee of Agreement State instrument calibration service provider attempted to modify or 

perform non-routine maintenance on a piece of calibration equipment that contained a 

radioactive source. At the time of the incident, the calibration device contained a 1.85 GBq 

(50 mCi) cesium-137 sealed source. The device had previously been designed and built by the 

licensee for their own use. The employee used a grinder to grind what was believed to be a 

metal spacer inside of the calibration device. When contamination was detected by another 

employee in the vicinity of the work area, the employees recognized that the piece of metal that 

had been ground actually contained a radioactive source. 

As a result, the licensee’s machine shop became contaminated. Also, due to the tracking of 

radioactive contamination by personnel, some other areas of the licensee’s facility became 

slightly contaminated. The licensee performed some decontamination activities themselves and 

retained the services of an appropriately licensed contractor to complete the decontamination 

activities. The licensee identified four individuals that might have been exposed to the 

contamination event. All four individuals underwent whole body counting. Three individuals 

were estimated to have received less than 0.1 mSv (10 mrem) CEDE. The fourth individual, 

who performed the grinding of the source, is estimated to have received 2.99 mSv (29.2 mrem) 

CEDE. 

DISCUSSION

The events described above each occurred during gauge dismantlement or non-routine 

maintenance operations that involved the handling or removal of sealed radioactive sources. In 

each event, radiation sources were damaged or breached, resulting in both radioactive 

contamination of individuals and licensee facilities. In each event, radioactive contamination 

was confined within the licensee’s facility, with no detectable release of radioactive material into 

the public domain. However, some licensee facilities were contaminated significantly, leading to 

long periods of time of facility closure and in most cases, necessitating decontamination 

services provided by a contractor. Also, in each case, licensee personnel were contaminated, 

often with both external radioactive contamination and some level of intake of radioactive 

material. Some employees with a suspected intake of radioactive material were sent for 

medical evaluation as a precautionary measure. Additionally, special dose analysis and 

assessment methods were necessary in some cases, including urine and fecal bioassay and/or 

lung or whole body counting. 

 

Common causal factors have been identified in the events described above that may have 

contributed to the damage to the radioactive sources, the subsequent release of radioactive 

material, and the resultant contamination of licensee facilities and personnel. The common 

causal factors have been identified as follows:
IN 2009-05 

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1. Dismantling/disassembling gauges or performing non-routine maintenance of devices 

based on intuition rather than reviewing the information contained in the sealed source 

and device registry (SS&DR) safety analysis or other information available from the 

source or device manufacturer or vendor. 

2. For an unfamiliar radioactive source or device, or in the absence of specific information 

about the configuration of the radioactive sources within the gauges or devices, 

licensees did not develop, document, and implement their own procedures to perform 

the dismantlement or non-routine maintenance activities. 

3. For the incidents that involved dismantlement or disassembly of gauges, the aged and 

potentially deteriorated condition of the gauges and/or radioactive sources at the time of 

dismantlement/disassembly was not taken into consideration by licensee personnel that 

were handling the sources or devices. 

This IN serves as a reminder of the importance for licensees to exercise caution when 

performing licensed activities that involve the handling or removal of sealed radioactive sources 

in gauges or devices. Prior to the start of any such activity, licensees should review specific 

information about the gauge, source holder, and/or device. This includes, as appropriate, 

information available in the SS&DR or other information from the manufacturer or vendor. In the 

absence of such information, licensees should themselves develop, document, and implement 

appropriate procedures, as well as train personnel on the procedures. 

When developing procedures, licensees should consider conducting dismantlement/ 

disassembly and other non-routine maintenance activities in a deliberate, stepwise manner, 

including conducting routine monitoring for radioactive contamination to promptly detect 

potential problems. Additionally, procedures should take into consideration actions that might 

be necessary to mitigate the consequences of radioactive source damage/rupture incidents. 

The availability of appropriate radiation detection equipment would assist personnel in 

determining the scope and extent of radiological contamination; which would, in part, help 

determine the necessary level of response. 

Regarding training, licensees might remain mindful that a successful training program should 

thoroughly familiarize employees with actions to take to limit the spread of contamination within 

licensee facilities and actions to take to successfully decontaminate personnel. Licensees 

should consider having appropriate supplies available in the event that the decontamination of 

personnel is necessary. Furthermore, a successful training program would help employees 

recognize actions that may be necessary to prevent the spread of radioactive contamination into 

the public domain. Finally, licensee employees should be trained to recognize conditions under 

which it might be necessary to seek external assistance, or notify as appropriate, NRC or other 

appropriate regulatory agencies. 
IN 2009-05 

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CONTACTS

This IN requires no specific action or written response. If you have any questions about the 

information in this notice, please contact one of the technical contacts listed below or the 

appropriate regional office. 

 /RA/ 

 

 Robert Lewis, Director 

 Division of Materials Safety 

 and State Agreements 

Office of Federal and State Materials 

 and Environmental Programs 

Technical Contacts: Lymari Sepulveda; FSME 

 (301) 415-5619 

 E-mail: Lymari.Sepulveda@nrc.gov

 Janine F. Katanic, Ph.D., CHP; FSME 

 (817) 860-8151 

 E-mail: Janine.Katanic@nrc.gov 

Enclosure: List of Recently Issued 

 FSME/NMSS Generic 

 Communications 
IN 2009-05 

Page 6 of 6 

CONTACTS

This IN requires no specific action or written response. If you have any questions about the 

information in this notice, please contact one of the technical contacts listed below or the 

appropriate regional office. 

 /RA/ 

 

 Robert Lewis, Director 

 Division of Materials Safety 

 and State Agreements 

Office of Federal and State Materials 

 and Environmental Programs 

Technical Contacts: Lymari Sepulveda; FSME 

 (301) 415-5619 

 E-mail: Lymari.Sepulveda@nrc.gov

 Janine F. Katanic, Ph.D., CHP; FSME 

 (817) 860-8151 

 E-mail: Janine.Katanic@nrc.gov 

Enclosure: List of Recently Issued 

 FSME/NMSS Generic 

 Communications 

ML090370785

OFFICE DMSSA/ASPB DMSSA/LB DMSSA/ASPB 

NAME JFKatanic: sxg6 LSepulveda ADWhite 

DATE 01/08/09 01/09/09 01/09/09 

OFFICE DMSSA/LB DMSSA/RMSB DMSSA 

NAME PRathbun AMcIntosh RLewis 

DATE 02/03/09 02/03/09 03/03/09 

OFFICIAL RECORD COPY
IN 2009-05 

Enclosure 

Page 1 of 1 

List of Recently Issued Office of Federal and State Material and Environmental Management Programs 

Generic Communications 

Date GC No. Subject Addressees 

05/13/08 RIS-2008-10 Notice Regarding Forthcoming Federal 

Firearms Background Checks 

All U.S. Nuclear Regulatory Commission 

licensees, certificate holders, and applicants for 

a license or certificate of compliance who use 

armed security personnel as part of their 

physical protection system and security 

organization. All Radiation Control Program 

Directors and State Liaison Officers. 

06/16/08 RIS-2008-13 Status And Plans for Implementation of 

NRC Regulatory Authority for Certain 

Naturally Occurring and AcceleratorProduced Radioactive Material 

All U.S. Nuclear Regulatory Commission 

materials licensees, Radiation Control Program 

Directors, State Liaison Officers, and the NRC’s 

Advisory Committee on the Medical Uses of 

Isotopes 

07/18/08 RIS-2008-17 Voluntary Security Enhancements for 

Self-Contained Irradiators Containing 

Cesium Chloride Sources 

All U.S. Nuclear Regulatory Commission 

Materials Licensees Authorized to Possess SelfContained Irradiators Containing Cesium 

Chloride (CsCl) ; all Agreement State Radiation 

Control Program Directors and State Liaison 

Officers; all members of the Advisory Committee 

on the Medical Uses of Isotopes. 

10/03/08 RIS-2008-23 The Global Threat Reduction Initiative 

(GTRI) Domestic Threat Reduction 

Program & Federally Funded Voluntary 

Security Enhancements For High-Risk 

Radiological Material 

All U.S. Nuclear Regulatory Commission 

Materials Licensees authorized to possess 

Category 1 or Category 2 quantities of 

radioactive materials. All Agreement State 

Radiation Control Program Directors and State 

Liaison Officers. Members of the Advisory 

Committee on the Medical Uses of Isotopes 

10/03/08 RIS-2008-24 Security Responsibilities Of Service 

Providers and Client Licensees 

All U.S. Nuclear Regulatory Commission 

licensees that hire service providers to install, 

service, repair, maintain, relocate, exchange, or 

transport radioactive materials in quantities of 

concern, service provider licensees, Agreement 

State Radiation Control Program Directors, and 

State Liaison Officers 

12/22/08 RIS-2008-10, 

Suppl. 1 

Notice Regarding Forthcoming 

Federal Firearms Background Checks 

All U.S. Nuclear Regulatory Commission 

licensees, certificate holders, and applicants for 

a license or certificate of compliance who use 

armed security personnel as part of their 

physical protection system and security 

organization. All Radiation Control Program 

Directors and State Liaison Officers 

Note: This list contains the six most recently issued generic communications, issued by the Office of Federal and State Materials 

and Environmental Management Programs (FSME). A full listing of all generic communications may be viewed at the NRC public 

website at the following address: http://www.nrc.gov/reading-rm/doc-collections/gen-comm/index.html