Guidance. Ionising Radiations

Transcription

1 Guidance Ionising Radiations Issue Date: June

2 Contingency Arrangements Incidents (real or suspected) and accidents involving spillages, exposures of persons to radiation doses above predicted levels, loss or theft of radioactive material must be: reported to the Radiation Protection Officer, Safety Services, as soon as possible after the event; reported to the Departmental Radiation Protection Supervisor and the Head of Department as soon as possible; Contact Numbers During Office Hours (0900 to 1700 hours, Mon - Fri) Radiation Protection Officer (RPO) Ext 4673 or 2726 Outside Normal Working Hours (Evenings and Week-ends) Security Control Ext 2222 ask them to notify Head of Safety Services and the University s Radiation Protection Adviser. In all incidents, provide as much information as possible. Follow all instructions/advice from RPO/RPA In every event first-aid to casualty takes precedence over dealing with contamination; minimise spread of contamination; if necessary, secure area; in the event of fire, advise Fire Brigade of location of radioactive material; refer all external enquiries regarding major incidents to the Press Officer (Ext 4123) Contingency plans giving details of the action to be taken in the event of an incident or accident should be incorporated into Departmental Safety Regulations and/or the individual risk assessment and safe system of work. 2

3 CONTENTS 1. Introduction University Policy 1.2 Background 1.3 Terminology 1.4 Aim and Scope of this guidance document 2. Principles of Radiation Protection Restriction of Exposure 3. Legal Requirements General 3.2 Ionising Radiation Regulations Radioactive Substances Act Administration of Radioactive Substances to Human Subjects 3.5 Carriage of Dangerous Goods and Transportable Pressure Equipment Regulations Other Relevant Legislation 4. Roles and Responsibilities University Management of Radiation Safety 4.2 Statutory Advice and Support Radiation Protection Adviser 4.3 Radiation Protection Officer 4.4 Heads of Departments / Directors of Service 4.5 Principal Investigators 4.6 Departmental Radiation Protection Supervisor Requirements and duties of RPS appointments 4.7 Radiation Workers 5. Registration, Authorisation and Notifications Types of Certificates 5.2 Single Site Licence Certificates 5.3 Exemption Orders 5.4 Variations to Registration and Authorisation Certificates 5.5 Notifications 6. Facilities for Radiation Work Laboratory Design 6.2 Designation of Laboratory / Facility Controlled Areas Supervised Areas Non-Designated Areas 6.3 Decommissioning of Laboratory Facilities 7. Departmental Local Rules Radiation Workers Registration 8.2 Dose Limits and Dose Constraints 8.3 Designation of Workers Classified Workers 8.4 New or Expectant Mothers 8.5 Visitors and Outside Workers 8.6 Contractors 8.7 Health Monitoring 3

4 8.8 Personal Monitoring by Dosimetry Dose Investigation Level 8.9 Biological Monitoring Urine Monitoring Thyroid Monitoring 9. Training Department Radiation Protection Supervisors 9.2 Radiation Workers 9.3 Safety Services Training Provision 10. Risk Assessments Radiation Risk Assessments and Safe Systems of Work 10.2 Review and Revision of Risk Assessments 11. Radioactive Material Sources Sealed Sources Sealed Source Marking and Certificate Leak Tests 11.2 Unsealed Sources 12. Radioactive Source Accountancy Inventory of Radioactive Materials 12.2 Ordering of Radioactive Materials 12.3 Receipt and Delivery of Radioactive Materials 12.4 Storage of Radioactive Materials 12.5 Stock Records for Radioactive Materials Unsealed Sources Sealed Sources and Exemption Order Holdings 13. Disposal of Radioactive Waste Solid Radioactive Waste Disposal with Ordinary Waste Disposal by incineration via Authorised Waste Contractor 13.2 Liquid (Water Soluble) Radioactive Waste 13.3 Gaseous Radioactive Waste 14. Contamination Control Measures Area Monitoring of Workplace 14.2 Portable Monitoring Equipment 14.3 Wipe Test Monitoring 14.4 Contamination Monitoring Records 14.5 Cleaning of Glassware 14.6 Spillage of Radioactive Material 15. Movement and Transport of Radioactive Materials Movement within the University 15.2 Transport outside of University Premises 16. X-ray Equipment Prior Authorisation 16.2 Restriction of Exposure 16.3 Exposure Controls Warning Devices Maintenance of Controls 16.4 Safe Systems of Work 4

5 16.5 Critical Examination by Installer / Erector 16.6 Monitoring Equipment 16.7 General Safety Precautions 17. Naturally Occurring Radioactive Materials (NORM) Radon Gas 18. Emergency Procedures Accidents Involving Radioactivity and Injury to the Person Unintended Exposure Accessible High Doses Spillages of Radioactive Material 18.2 Fire in Laboratories 18.3 Physical Damage 18.4 Missing Radioactive Substance 18.5 Notification of Certain Occurrences 19. Key Management Actions References, Guidance and Further Reading Appendices 1 University Radiation Safety Management Structure 49 2 Guidelines for Commencing Work with Ionising Radiation 50 3 Guidelines for Commencing Work with X-ray Equipment 51 4 Abbreviated Local Rules for Designated Areas 52 5 Written Arrangements for entry to Controlled Areas 53 6 Record of Dept. Training in Radioisotope Procedures 55 7 Record of Dept. Training in Use of X-ray Equipment 56 8 Contingency Plan for Room 57 9 Radiation Monitors Summary of Series 900 Mini Monitors Wipe Testing Methodology Excerpt of Common Radionuclides (Schedule 8 of IRR99) Common Definitions / Glossary of Terms 62 5

6 Work with Ionising Radiations No radioactive substances may be brought into, or removed from any department of the University without prior authorisation from the Departmental Radiation Protection Supervisor (or the Radiation Protection Officer in some cases). Form RP1 should be completed prior to any material coming into the University. Similarly, equipment which may produce X-rays, whether intentionally or adventitiously may not be commissioned without authorisation from the Radiation Protection Officer. Any new, recommissioned or re-located apparatus which is designed to produce X-rays must, before being used for the first time, be subjected to a critical examination by those installing or commissioning it. This will be done in conjunction with the University s Radiation Protection Adviser. Departments using ionising radiations must ensure that they have appropriate Departmental Local Rules and / or Safety Management Arrangements covering all aspects of ionising radiation within the department. 1. Introduction 1.1 University Policy It is the Occupational Health and Safety Policy of the University of Strathclyde to ensure, so far as is reasonably practicable, the health, safety and welfare of all its employees at work, of students while they are engaged in activities under the supervision of the University and of members of the general public who may have access to University property. The University s Health and Safety Management Arrangements for Work with Ionising Radiations includes a Local Rule, which identifies the key management requirements for all departments, along with additional supporting documents, including this guidance document. 1.2 Background Ionising radiations occur as either electromagnetic rays (such as X-rays and gamma rays) or particles (such as alpha and beta particles). It can occur naturally (e.g. from the radioactive decay of natural radioactive substances such as radon gas and its decay products) but can also be produced artificially. People can be exposed externally, to radiation from a radioactive material or a generator such as an X-ray set, or internally, by inhaling or ingesting radioactive substances. Various activities involving the use of materials with ionising radiation properties or equipment capable of producing ionising radiation are used within the University. 1.3 Terminology Please refer to Appendix 13 for a glossary of common radiation terms and definitions. 6

7 1.4 Aim and Scope of this Guidance Document This document is intended to serve as a guide to departments and individuals using or having responsibility for working with radioactive materials or radiation generating equipment. It aims to support the University s Local Rule for Work with Ionising Radiation and ensure compliance with current legislation and to ensure good practice is adhered to in order to protect individuals and the environment from possible radiation exposure. It describes the roles and responsibilities of various groups and individuals; the University s safety management structure, operating procedures, standards and practices for the safe use and management of ionising radiation within the University. It is recognised that not all aspects of this guidance will apply to all types of ionising work (e.g. unsealed source and X-ray equipment) and users should ensure that they refer to all relevant sections in line with their particular work requirements. This document covers the majority of ionising radiation issues that are likely to be encountered in the University (including the production of adventitious X-rays by high voltage electrical equipment greater than 5kV) and describes the safe means of working with ionising radiations. However, certain circumstances or situations may have specific requirements and in these cases the precise nature of Departmental Local Rules may vary and subsequently they may apply to an entire department, a single laboratory or to one source. Contact Safety Services for further advice. Departmental Local Rules must be prominently displayed and brought to the attention of all relevant employees and radiation workers. Failure to adequately protect individuals against radiation exposure may lead to ill health in individuals; damage to the environment and possible prosecution by Enforcing Authorities for breaching legislation. The University will ensure that the following objectives are met for all work involving ionising radiations: Dose limitation no University employee, student, visitor or any other person will receive a dose of ionising radiation in excess of any relevant dose limit. As low as reasonably practicable (ALARP) the University, through its practices and procedures, shall ensure that exposure to ionising radiation is as low as reasonably practicable. The University will ensure that the use of radioactive materials (within the University) will have no detrimental impact on the environment. Consideration will always be given to alternative methods to those involving ionising radiations. All members of University staff working with any source or potential source of ionising radiation should make themselves aware of the standards expected of them, which are detailed within this guidance document. 7

8 2. Principles of Radiation Protection The University upholds the three internationally recognised principles of the International Commission on Radiation Protection (ICRP 60): 1) Justification the use of ionising radiations must be justified and produce a common benefit. Consideration must be given to alternative methods, which do not involve ionising radiations. 2) Optimisation all exposure to ionising radiations must be as low as reasonably practicable (the ALARP principle) with both economic and social factors being taken into account. 3) Dose Limits exposure to individuals should be subject to the relevant dose and risk limits. 2.1 Restriction of Exposure In order to restrict potential exposure and ensure dose limits are kept well below regulatory limits, a hierarchy of control measures should be applied during the design, construction, installation and use. These measures will normally include consideration to: Whether the use of radioactive materials or X-ray producing equipment is needed and the benefits can be justified against the possible risks. Assessing if the experimental work can be carried out by other, suitable nonradioactive techniques or procedures which are less hazardous. Using the minimum amount of radioactive material as possible for the work activity. Substituting radionuclides with less hazardous ones where possible. For example using Phosphorus-33 (P-33) instead of Phosphorus-32 (P-32). Minimising exposure time of radiation workers to radioactive materials. For example this may include performing dummy experimental runs without any radioactive material involved to ascertain handling times and increase the workers familiarisation of new handling techniques or procedures. Ensuring facilities have been carefully designed, designated where appropriate and are suitable for the ionising radiation work being performed. Where possible it is preferable to have ionising work areas segregated from non-ionising work areas. Ensuring work equipment is appropriate for the work involved and where possible affords protection through the principles of shielding and distance. Ensuring radiation workers are suitably and appropriately trained in the hazards of the radionuclides being used and the procedures and measures required to minimise the risk. Ensuring Local Rules, risk assessments, systems of work and departmental safety arrangements and procedures are in place for the work activities. Providing suitable and appropriate Personal Protective Equipment (PPE) such as laboratory coats, safety glasses, lead shielded aprons, disposable gloves and ensuring changing and storage facilities are available if and where required. Encouraging good house-keeping and hygiene practices are observed and adhered to. Ensuring suitable contamination monitoring and procedures are in place for work areas. Ensuring personal monitoring (e.g. dosimetry) and health surveillance schemes, (where appropriate) are in place for radiation workers. 8

9 3. Legal Requirements 3.1 General The Health and Safety at Work, etc, Act 1974 (HSWA) and the Management of Health and Safety at Work Regulations 1999 (MHSWR) set out requirements for employers to provide a safe place of work, safe systems of work and to carry out risk assessments covering all work activities. 3.2 The Ionising Radiations Regulations 1999 (IRR99) These Regulations set out the requirements for work with ionising radiations. Their purpose is to ensure that exposure to ionising radiations arising from work activities, is kept as low as reasonably practicable. The Regulations are supported by an Approved Code of Practice and Guidance, which have been used to produce these Local Rules. These Regulations are enforced by the Health and Safety Executive (HSE). It should be noted that in relation to X-ray generating equipment, such equipment, in particular circumstances, may require prior approval from the HSE before purchase and use and advice should be sought from Safety Services in such cases. 3.3 The Radioactive Substances Act 1993 (RSA93) This Act permits the acquisition, storage and disposal of radioactive material. Every department must be registered with a certificate to hold and use radioactive material and must be authorised by certificate to store and dispose of radioactive waste material. These certificates are issued and enforced by the Scottish Environment Protection Agency (SEPA) and each certificate contains specific conditions which must be strictly adhered to. The certificates relate specifically to the University s use of radioactive material for research and teaching. Certificates must be displayed in every laboratory/storage area that uses/stores radioactive material and all radiation workers must be fully aware of the conditions attached to these certificates. The University can be inspected at any time by enforcing authorities and is normally inspected at least annually by SEPA. 3.4 Administration of Radioactive Substances to Human Subjects Any person who administers radioactive material to humans must hold a certificate issued by the Administration of Radioactive Substances Advisory Committee (ARSCA). Each study requires a separate certificate and must have the approval of the Ethics Committee prior to work commencing. There is no work of this type carried out in the University at the present time. For further information please contact the Radiation Protection Officer (RPO). 3.5 Carriage of Dangerous Goods and Transportable Pressure Equipment Regulations 2011 (CDG2011) These Regulations are based upon the International Atomic Energy Agency s (IAEA) Regulations for the Safe Transport of Radioactive Materials and the European Agreement relating to the International Carriage of Dangerous Goods by Road. The basic philosophies behind the regulations are that: Package design should be such that the risk of any radioactive contamination or external radiation hazard should be kept to a minimum. That all shipments should be traceable back to the sender. That good quality assurance should produce public reassurance. 9

10 Within the Regulations there is a category of exempt radioactive material which defines what is considered as significant radioactive material (and is radionuclide specific) under the transport regulations (Refer to Section 15 for further details on transport). 3.6 Other Relevant Legislation There are a number of other pieces of legislation that may also apply to activities involving ionising radiations, and some are covered by other University Local Rules, for example, Local Rules for Control of Substances Hazardous to Health (COSHH) and Electrical Safety. Contact Safety Services for further information. 4. Roles and Responsibilities 4.1 University Management of Radiation Safety The University Court and Senior Officers carry the general, legal responsibility for compliance with the IRR99, the RSA93 and other relevant legislation within the University as a whole. Within individual University departments, legal responsibility for compliance with the above legislation (as with all other health and safety legislation) rests with the Heads of Departments/Directors of Services/Head of Schools. However, for administrative purposes, the Head of Department/Director of Service may delegate the function of this duty to a Departmental Radiation Protection Supervisor (DRPS); they cannot delegate the duty. Refer to Appendix 1 for the University Occupational Health and Safety Management Structure. 4.2 Statutory Advice and Support Radiation Protection Adviser Radiation Protection falls within the remit of Safety Services which is responsible for providing advice, Local Rules and guidance on radiation safety. The University, as required by the IRR99 (Reg. 13) have appointed an external Radiation Protection Adviser (RPA) to be a source of advice on all matters relating to radiation safety. The RPA provides assistance in determining hazards and assessing and proposing the necessary protective controls and procedures required. The RPA will endeavour to keep the University informed of changes to legislation and standards relating to the University s use of radiation. The RPA will also be consulted in the design of all engineering and procedural controls used to minimise exposure to ionising radiations. In summary, the University has applied the following control measures to ensure that exposure to ionising radiation is ALARP by: Providing advice and assistance on all matters of ionising radiation safety. Providing basic core radiation training for all personnel working with ionising radiation. Ensuring departmental risk assessments for all activities involving radioactive materials or potential sources of ionising radiation are reviewed. Providing University Local Rules and guidance on ionising radiation. Designation of areas for radiation work as controlled, supervised or nondesignated according to potential hazard and risk levels. Implementing procedures for the acceptance, purchase and disposal of radioactive materials to ensure regulatory compliance can be achieved. Ensuring records are kept and an inventory of sources is updated at periodic intervals. Regularly auditing departmental procedures, facilities and management for work with ionising radiation. 10

11 4.3 Radiation Protection Officer A Radiation Protection Officer (RPO) has been appointed by the University to work with the RPA and departments to manage all matters relating to work with ionising and non-ionising radiation throughout the University. The RPO will be responsible (on behalf of the University) for the following: Ensuring the requirements of IRR99 are met. (It should be noted that legal responsibility to ensure compliance remains with the University.) Facilitating the work of the RPA, and other external bodies, within the University. Managing the University s radiation protection programme e.g. auditing, training and the radiation waste store. Advising on general radiation matters. Liaising with DRPS. Reporting to the University Safety Committee on radiation matters. 4.4 Heads of Department / Directors of Services Heads of Departments (hereafter used to include Directors of Services/Heads of Schools) are legally responsible for the management of health and safety within their departments. Their responsibilities with particular reference to ionising radiation are to ensure that arrangements are in place within their department to meet the requirements of the University s Local Rule on Work with Ionising Radiation. Where ionising radiations are used, there is a legal requirement under IRR99 (Reg. 17.4) for the Head of Department to appoint in writing (form RP2) one or more DRPS (depending on size, activities etc). These appointments must be registered with Safety Services. The DRPS will assist the Head of Department to ensure compliance with the University Local Rules and the appropriate legislation. Where appropriate a deputy DRPS should be appointed to cover in the absence of the DRPS. 4.5 Principal Investigator The Principal Investigator (PI) who is responsible for the work involving ionising radiations also has a legal duty to ensure the appropriate health and safety management of the project / work. The PI will ensure that all risk assessments involving ionising radiation are sent to the DRPS who will forward them to Safety Services for consultation with the RPA. After noting comments received and implementing recommendations from Safety Services, the DRPS will be responsible for giving departmental approval on behalf of the Head of Department. The PI must ensure that the findings of the risk assessment are incorporated in a written safe system of work and implemented prior to works commencing. The PI must also ensure that all radiation workers under their supervision comply with the appropriate departmental Local Rules and are given appropriate departmental training in safety procedures and experimental techniques to carry out the work safely. They are responsible for implementing appropriate and suitable supervision for all radiation workers under their line manager. 11

12 4.6 Departmental Radiation Protection Supervisors The function of the DRPS is to supervise the arrangements set out in University and Departmental Local Rules and assist the Head of Department in ensuring compliance and adherence to all relevant legislation covering work with ionising radiations. It is a legal requirement (IRR99, Reg. 17(4)) that departments working with ionising radiation appoint in writing suitable and appropriate DRPS to assist in the radiation safety management and supervising arrangements set out in Local Rules. The following categories apply to ionising radiation DRPS: RPS (radioisotopes) RPS (X-ray) All new DRPS must attend a suitable and appropriate RPS general training course and will be given an induction of their duties upon receipt of their appointment. Contact the RPO for further details Requirements and duties for DRPS appointment The main requirements of DRPS include the following: Know and understand the requirements of the regulations and the University Local Rules relevant to work with ionising radiations. Be aware of radiation work undertaken in the department and exercise appropriate supervision. Assist PI in preparing departmental radiation risk assessments and safe systems of work (SSW) for RPA review. Ensure suitable departmental procedures are in place for the ordering, storing, dispensing and disposal of radioactive material and that these procedures are carried out in accordance with the University and Departmental Local Rules and applicable Certificates of Registration and Authorisation. Ensure new workers of ionising radiation are registered with Safety Services on form (RP8) and notify Safety Services when radiation workers leave. Notify Safety Services if any significant changes occur in the radiation worker s activities (e.g. change in radionuclides handled, significant increase in radioactive workload, number of experiments etc). Ensure all new radiation workers receive basic core training (organised by Safety Services). Provide departmental training to new workers (often in conjunction with the PI). Ensure relevant departmental records are retained e.g. stock control, waste disposal, training and monitoring records. Co-ordinate with any contractors on site that may involve areas of ionising radiation. Liaise with Safety Services, RPA, University Management, and when required, external enforcing agencies. Manage requirements and requests for critical exams, checks of equipment, calibration of monitoring equipment and for leak testing of sealed sources. Management of departmental dosimetry arrangements. 12

13 4.7 Radiation Workers All personnel working with radioactive materials or sources of ionising radiations shall work in accordance with the following: University Local Rules, Departmental Local Rules, risk assessments and written systems of work. Every radiation worker must receive appropriate radiation training, prior to work commencing, and a written record of this training must be retained. All radiation workers, i.e., permanent, parttime, contract staff, post-graduate students, must be registered RP8 with Safety Services prior to commencing work. Undergraduate students involved with ionising radiations, outwith those covered by normal class work, for example final year projects students, may also require to be registered. Further advice can be obtained from Safety Services. It is expected that every radiation worker shall: Not knowingly expose themselves or any other person to ionising radiations and shall exercise care when carrying out such work. Follow guidance and good laboratory practice. Make full and proper use of any equipment (e.g. monitoring equipment, shielding) or Personal Protective Equipment (PPE) provided (e.g. laboratory coats, gloves etc). Report any defects discovered in such equipment or PPE to appropriate personnel. Take all reasonable steps to ensure that equipment and non-disposable PPE, are returned after use to the appropriate storage area in safe and an uncontaminated manner. Follow all risk assessments, systems of work, local rules, instructions, information and training whilst working with ionising radiation. Notify the DRPS (or Safety Services) if any significant changes occur in the radiation worker s activities (e.g. change in radionuclides handled, significant increase in radioactive workload, number of experiments etc). In the case of Classified Workers or Outside Workers, special arrangements and procedures are required and must be adhered to (e.g. health medicals, radiation passbooks etc). See section also or contact Safety Services for further information. 5. Registration, Authorisation and Notifications RSA93 requires users of radioactive material to register with the appropriate enforcing authority, the Scottish Environment Protection Agency (SEPA), and to obtain the appropriate certificates prior to the purchase, storage, use and disposal of radioactive material on University premises. 5.1 Types of Certificate Certificate of Registration (closed sources) - Permits the holding of sealed radioactive material, e.g. calibration sources, level gauges, etc. Certificate of Registration (unsealed sources) - Permits the holding of solid, liquid or gaseous radioactive material, e.g. pharmaceutical products. Certificate of Registration (Mobile Radioactive Apparatus) - Permits the holding of apparatus designed to contain radioactive material and be transportable. 13

14 Certificate of Authorisation - Permits the accumulation and disposal of radioactive material. Registration certificates are issued to University departments and place conditions on the maximum type, number and total activity of radioactive material the department may hold. Departments are not permitted to hold radioactive materials in excess of the types, quantities and activities specified in the certificate. Authorisation certificates are issued to departments and stipulate the type, quantities and activities radioactive waste material that may be accumulated and the time period and specified routes of disposal. Again departments must not breach any of the conditions set out in these certificates. 5.2 Single Site Licence The University has a Single Site Licence (SSL) for the Registration and Authorisation of all unsealed radioactive material. Safety Services issues departments using unsealed radioactive material internal certificates with specific radionuclide and activity allocations, based on their departmental requirements, from the SSL Registration and Authorisation certificate allowances. These allocations MUST be adhered to in conjunction with the terms and conditions of the SEPA SSL Registration and Authorisation Certificates. Departments must also maintain accurate source and disposal accountancy records to demonstrate compliance with both the internal allocations and the SEPA certificate terms and conditions through the use of the web based computerised SPIDER radiation database system. Although the SSL permits the University an increased level of flexibility, it may not be able to meet the requirements of significant changes in current use and in such cases; an application to vary the SSL may be required (See 5.4 below). 5.3 Exemption Order In some incidences, specific radioactive material may be exempt from registration or authorisation. Exemptions made under The Radioactive Substances Exemption (Scotland) Order 2011 have specific conditions attached, which must be complied with. 5.4 Variations to Certificates of Registration or Authorisation Departments that wish to alter their current Registration or Authorisation certificates must discuss this with the RPO in the first instance. Where possible the variation will be accommodated internally under Single Site Licence certificates for unsealed sources. However, where this is not possible (e.g. in the case of closed sources), the University will need to apply for a new/amended certificate of registration or authorisation and this process can take 4-6 months. Thus it is advisable that departments notify Safety Services as soon as possible of any future changes that may be required, in order to minimise any potential delays that could impact on the future research work or planned project. Departments must also inform Safety Services of ALL radioactive materials being brought on to University premises (excluding the routine and regular purchasing of radionuclides) whether the user thinks that they may be exempt or not. On no account should radioactive material be taken into a department where it does not comply with the departments certificates. All such requests must be brought to the attention of the DRPS. 14

15 5.5 Notifications Under IRR99 the University is required to notify the HSE and obtain authorisation for the following: Commencement of new types of work with ionising radiations for the first time - at least 28 days notice must be given to the HSE before work commences. The use of X-ray equipment. The use of accelerators. Any significant change in the above work. Some of the above working practices may be exempt from prior notification and others may be covered by generic authorisations (see Section 16.1) provided by the HSE, if the University shows it can satisfy all appropriate conditions laid down by the HSE. Again, departments must notify Safety Services if any of the above are likely to apply to new or future planned activities in order to confirm exemption or the requirement for notification. 6. Facilities for Radiation Work 6.1 Laboratory Design Prior to the designation, refurbishment or building of any new laboratory space where unsealed radioactive work will take place, consultation must take place with the RPO / RPA regarding the suitability and design of the proposed or new facilities. The following design considerations are based upon the Environmental Agency Guidance as incorporated in the AURPO Guidance Notes on Working with Ionising Radiations in Research and Teaching, December 2010 document. Any area where unsealed radiation work takes place should be designed and equipped to: Afford the correct protection to the worker. Restrict the spread of contamination. Allow for easy decontamination. The basic standards for any radiation laboratory within the university are as follows: Work surfaces must be impervious to spillages, cleanable and gaps and edges sealed. Floor coverings must be impervious to spillages, cleanable and where possible be a continuous sheet or welded. Walls and ceilings should be smooth and painted with an acrylic or similar emulsion to provide a hard durable and washable surface. Sinks should be stainless steel or of other suitable material cleanable and where possible have combined draining board and suitable splash guard * Sinks and waste pipes must be clearly identified and suitably labelled if used for the disposal of radioactive liquid waste and main route to sewer identified. A separate sink must be reserved and identified for hand washing with elbow /foot operated taps (where possible). Provision or access to an emergency shower must be considered. There must be good ventilation. Any containment facilities e.g. fume cupboard and ducting must meet current British Standard (BS). There must be suitable secure storage areas for both stock and waste radioactive material. 15

16 Seating must be non-upholstered or upholstered in a non-absorbent material. Appropriate warning signage must be displayed which complies with BS: and The Health and Safety (Safety Signs and Signals) Regulations Adequate lighting must be provided. Exposed wood must be painted or sealed. Coat hooks should be available and used for the storage of lab coats. * Some materials are not suitable for use with certain isotopes, i.e., P-32 with stainless steel, although this should not normally be an issue for the amounts normally in use in the University. If in doubt, please consult with the RPO. For high hazard laboratories or in some cases, Controlled / Supervised areas, the standard is expected to exceed the minimum listed above. For further advice on the design and categorisation of laboratory space please contact the RPO. 6.2 Designation of Laboratory / Facility Radiation work is only permitted in areas, laboratories or rooms, which have been suitably designated and approved by Safety Services in accordance with advice from the University s RPA. Each department must maintain a register of all such areas. In the University, areas are designated as controlled, supervised and non-designated (e.g. a general laboratory where only very low level radiation work is carried out). The designation of an area will be the outcome of a risk assessment and be dependent on the nature of the work to be undertaken in that area. Factors to be considered include the: external and internal radiation hazard, nature of the radiation, potential for spread of contamination, location of the facility, other uses and users of the facility. The RPA must be consulted when deciding the designation of an area. The two types of areas recognised by IRR99 are: Controlled Area Supervised Area Where an employee is likely to receive doses of radiation in excess of 6mSv in a year or where special procedures are required to restrict exposures to less than 6 msv per year. Access to Controlled areas is restricted to classified persons only or those who are working under a written scheme of work which will ensure that dose levels are acceptable. Under IRR99 dose rates in excess of 7.5 microsieverts per hour* may be found in these areas. Where an employee is likely to receive doses of radiation in excess of 1mSv per year and / or conditions need to be kept under review to ensure that designation as a Controlled area is not required. Under IRR99 dose rates of between 2.5* and 7.5 microsieverts* per hour may be found in these areas. * All dose rates quoted are the time-averaged dose rate over a working day. 16

17 6.2.1 Controlled Areas An area is designated as a Controlled Area if: Any worker is likely to receive an effective dose greater than 6mSv a year, an equivalent dose greater than 3 / 10 of any relevant dose limit or exposed to dose rates in excess of 7.5 μsv h -1*. Any person is required to follow special procedures designed to restrict doses to less than 6mSv per year. There is a significant risk of spreading contamination outside the work area. It is necessary to prevent, or closely supervise, access to the area by non radiation workers. * All dose rates quoted are the time-averaged dose rate over a working day. If the risk assessment indicates a Controlled Area then the following criteria must be met: The area must be clearly demarcated indicating the extent of the Controlled Area; this may be an entire room or a section of a laboratory. Suitable warning signs conforming to the Health and Safety (Safety Signs and Signals) Regulations 1996 must be displayed. Signs must include the trefoil symbol and the words Controlled Area. Access to such areas is confined to authorised radiation workers working under special written arrangements or to classified workers (Refer also to Section 8.3). Areas may be temporarily designated Controlled Areas only if the status is clear to all personnel at all times and special written arrangements are clearly defined in the written System of Work Supervised Areas An area is designated a supervised area if Any worker is likely to receive an effective dose greater than 1mSv a year, an equivalent dose greater than 1/ 10 of any relevant dose limit (see Section 8.2) or exposed to dose rates in excess of 2.5 μsv h -1*. Conditions must be kept under review if the area has the potential to become a Controlled area. * All dose rates quoted are the time-averaged dose rate over a working day Non-Designated Areas Some areas of the University, where radiation exposure is unlikely to result in radiation doses greater than 1mSv per year and where the dose rates are below 2.5 μsv h -1* are classed as non-designated areas. Only very low level work with ionising radiations may be carried out in these areas. * All dose rates quoted are the time-averaged dose rate over a working day. 17

18 6.3 Decommissioning of Laboratory Facilities Any designated radioactive area/laboratory to be vacated or redesignated as a nonradioactive work area must be suitably decontaminated prior to the change of use. Laboratory decommissioning is not considered a normal operation and is therefore subject to prior risk assessment and authorisation by Safety Services prior to commencement. In essence the department responsible for the area must carry out, in consultation with the RPO and RPA, a detailed programme of monitoring and where necessary decontamination and retain a written record of such work. The department must provide a copy of the record to both Safety Services and Estates Services before any outside contractor or Estates Services staff are allowed to work in the area or remove any fixtures or fittings. SEPA may also request a copy of this information in relation to the conditions of department s Registration/Authorisation certificates. For further information contact the RPO. 7. Departmental Local Rules IRR99 (Reg. 17(1)) requires Local Rules to be written for any area designated as controlled, or where appropriate, as a supervised area (see previous section). These should identify the key working instructions intended to restrict exposure to ionising radiations and information relating to departmental procedures for the management of any work involving ionising radiations. Each department involved in such work must produce a set of departmental local rules. When Local Rules are written or amended then it is required that they are forwarded for consultation with the University s RPA. Department Local Rules can either be incorporated within Departmental safety arrangements/regulations or they may be prepared as a separate stand alone document, which should be cross-referenced within the Departmental safety arrangements/regulations. Departmental Local Rules must include the following: The name and contact details of the DRPS. The area(s) that the rules apply to and the designation of the area(s). Contingency arrangements for foreseeable accidents or incidents. Dose investigation levels set by the department. A summary of working instructions to keep exposure ALARP. Optional but recommended inclusions: How the work will be managed and supervised. Information on the frequency and nature of radiation and contamination monitoring. Information on the frequency and nature of testing and maintenance of engineering controls, safety features and warning devices. Information on the choice and use of suitable monitoring equipment. Information on departmental accountancy procedures. Personal dosimetry requirements. Arrangements for pregnant or breast-feeding workers. Arrangements for visiting workers and contractors. The departmental Local Rules should be reviewed periodically to ensure they remain relevant and up-to-date. 18

19 8. Radiation Workers 8.1 Registration All persons working with ionising radiations, (e.g., open and closed radioactive sources and X-ray generating equipment), within the University, are to be treated as radiation workers and must be registered with Safety Services. The University s Local Rules for Work with Ionising Radiations apply to them and must be adhered to. 8.2 Dose Limits and Dose Constraints The current legislative dose limits, specified under IRR99, aim to keep the average exposure of a radiation worker to an acceptable level. Exposure up to the dose limits is not considered acceptable, and all doses must be kept AS LOW AS REASONABLY PRACTICABLE. Table 1: Current Dose Limits set in milli sieverts (msv) per year Effective dose Equivalent dose (whole body) skin or extremities Category For all radiation workers aged 18 years or over For trainee radiation workers, aged under 18 years For any other person including members of the public Equivalent dose (lens of eye) 20 msv 500 msv 150 msv 6 msv 150 msv 50 msv 1 msv 50 msv 15 msv Dose Limits for Women of reproductive capacity are: A limit to the abdomen of 13 msv in any consecutive 3 month period A dose constraint of 1 msv for the foetus during the term of pregnancy. Source: Ionising Radiation Regulations, 1999 (Schedule 4, Reg. 11) A dose constraint is a reasonably achievable target limit, which indicates best practice and ensures doses are kept well below the limits set out under IRR99. Within a University context all radiation workers should be able to keep to within a dose constraint of 1mSv. This target is considered reasonably achievable and means that men and women can generally be treated the same with no undue concern should a woman become pregnant. However, it must be recognised that the foetus will preferentially absorb the important body building elements of phosphorous and calcium and thus any intake by the mother of radioactive isotopes of these elements could lead to significantly higher doses in the foetus than the mother receives. 19

20 8.3 Designation of Workers As an outcome of the risk assessment, registered radiation workers may be designated as classified or supervised workers. Table 2: Classified and Supervised Radiation Workers Classified Workers Any radiation worker who is likely to receive an effective dose of more than 6mSv/year or more than 3 / 10 of any relevant annual dose limit is designated as a classified person and is required to undergo annual medical surveillance as a condition of the designation under IRR99. Supervised Workers All other persons working with ionising radiations but who are unlikely to reach 1 / 10 of the appropriate dose limit are designated by the University as supervised radiation workers. Source: Ionising Radiation Regulations, 1999 (Reg. 16) Personal dosimetry records over many years indicate that most University radiation workers are highly unlikely to receive a radiation dose in excess of 1mSv per year from their radiation work activities in the laboratory. However, it should be noted that the University considers it prudent in many cases for departments to provide personal dosimetry to non-classified registered radiation workers as a means of ensuring control measures are suitable and for reassurance purposes of individuals Classified Workers All classified radiation workers must receive personal dosimetry after an initial blood and medical examination by an appointed doctor. They are also required to have an annual review of health through the University s Occupational Health Service (see Sections 8.7 and 8.8 also). 8.4 New or Expectant Workers Whilst there is no specific prohibition of pregnant workers from working with ionising radiations, it is extremely important that female members of staff and students are informed of the importance of declaring their pregnancy, in writing, to the Head of Department (or Principal Investigators and Course Supervisors in the case of students) and Human Resources as soon as possible. Safety Services should then be informed and a specific risk assessment of the radiation work will be completed prior to any further radiation work being carried out. For the majority of expectant mothers there is unlikely to be a requirement to alter their job/research practices as the radiation doses received during the pregnancy will be well below the permitted limit of 1mSv for the foetus. However, as IRR99 specifies special dose limits (see Section 8.2) to pregnant workers, the University may need to review the worker s ionising radiation activities for the remainder of their pregnancy. This will require taking into account the radionuclides, quantities and frequency of radiation work carried out in the research laboratory. External radiation is unlikely to pose a risk to the foetus, especially if it is from a low beta emitter. However, an internal hazard could be a factor dependent on the quantities and radionuclides used and thus it may be desirable to limit the handling of stock materials of the higher energy beta and gamma emitting sources. 20

21 It is also important to consider if any internal risk from the radiation work could apply to nursing mothers who return to work. Additional protection measures can be identified during the New and Expectant Mothers (NEMS) risk assessment, which is undertaken on notification that a female member of staff or student is pregnant. Contact Safety Services for further details. 8.5 Visitors and Outside Workers If visiting radiation workers or other persons are to enter controlled or supervised areas, then arrangements must be made to ensure that the appropriate dose limits are not exceeded. Long term visitors should be treated the same way as staff and students, in terms of registration, training and provided with personal dosimetry, if required. In circumstances where a classified worker carries out services or work in a Controlled area of another employer (or external research establishment), then the person is termed an outside worker. All outside workers must be in possession of a radiation passbook in which details of their outside work, any doses received and of their fitness to work can be recorded. Where a classified person visits another radiation employer s Controlled area for the sole purpose of an educational visit, they shall not be regarded as an outside worker on this occasion and a radiation passbook will not be required. It should be noted that regulations relating to outside workers do not apply if the outside worker takes over management of the Controlled Area for the duration of the work, which may be the case for particular service engineers. Any worker registered by the University as a radiation worker, or any member of staff or student who is not a registered radiation worker but who may be expected to enter any type of radiation area while working in another establishment, i.e., controlled, supervised or non-designated areas, must discuss the health and safety management arrangements of such work in advance with Safety Services. 8.6 Contractors All contractors (and their employees) must be informed and/or be familiar with the hazards and risks associated with departmental locations, equipment or activities involving, using or producing ionising radiation. The University has produced a guidance document for departments engaging external service providers and has also produced Contractors Local Rules for Safe Practice. The aim of these documents is to ensure that a satisfactory exchange of information on risks and control measures occurs between all parties concerned prior to work commencing. ln many instances, the DRPS (acting in the capacity as a University Supervising Officer) should be approached in the first instance to ensure adequate information is exchanged between parties. 8.7 Health Monitoring The University s Occupational Health Service has an appointed doctor, approved by the HSE for the purposes of medical examinations and health surveillance of classified radiation workers and others under IRR99. Contact details below: Occupational Health Service, Telephone: University of Strathclyde, Level 1, occupationalhealth@strath.ac.uk Livingstone Tower, Richmond Street, Glasgow, G1 1XH 21

22 8.8 Personal Monitoring by Dosimetry Any person who is likely to receive a radiation dose in excess of three-tenths of any relevant dose limit is required to be a classified radiation worker and must have their exposure to radiation monitored. Additionally, any worker who works in a Controlled Area either has to be classified or work under special written arrangements, and both normally include the need for personal monitoring. As mentioned previously, the University, goes further than these basic requirements, and recommends that departments issue body monitoring devices to all staff/students who work with penetrating radiations, unless their possible exposure can be shown to be negligible. The requirement for dosimetry is formally notified as part of the registration process for radiation workers, although th RPO/RPA can advise on this area if required. Work with alpha emitters or weak beta emitters, such as H-3, C-14, S-35, P-33 or Ca-45, does not require the wearing of body badges. It is important that all radiation workers issued with a thermoluminescent dosemeter (TLD), also referred to as a body badge, must ensure it is worn correctly and at all times when working with ionising radiations. Some radiation workers who work with particularly penetrating radiations may also be supplied with extremity dosemeters (fingerings) to wear in addition to the TLD. The University uses an HSE Approved Dosimetry Service (ADS) provider for this service. Departments are required to manage the service and investigate any reported doses. In the case of Classified Workers, Safety Service will monitor the dose readings and retain the radiation health records for these individuals. The minimum detectable level of radiation on a body badge is 0.01 msv for X or gamma radiation and 0.1mSv for beta radiation and, although the official investigation level for radiation exposures is 15mSv, at the University we would expect any exposure significantly above the minimum detectable amount or anything higher than that normally expected to be investigated, to ensure that all personnel exposure to ionising radiations is being kept as low as possible. An example of a body (TLD) badge and extremity dosemeters issued for personal monitoring purposes. 22

23 8.8.1 Dose Investigation Level The purpose of a dose investigation level is to set a trigger where doses might be indicating that they are not As Low As Reasonably Practicable (ALARP). Departments are required to carry out an investigation to check that doses are ALARP and, if not, ensure changes to working practices are made. A report of the investigation made will be kept for two years in most cases and longer in certain circumstances. In most cases, the top 10% of a dose pyramid would be the basis of determining a suitable investigation level. However, as the doses incurred by radiation workers in the University are very, very low, a 13-weekly assessed body or extremity dose reading of more than 0.1mSv as an investigation level is considered appropriate in order to demonstrate that doses are ALARP. If the aggregated annual dose exceeds 20mSv body dose or 500mSv extremity dose, the Health and Safety Executive (HSE) must be informed, however from past dose history, it is considered highly unlikely that University radiation workers will come near these specified levels. 8.9 Biological Monitoring Biological monitoring may be required for registered radiation workers who handle large activities of unsealed radionuclides and where there is a significant risk from the inhalation or ingestion of radioactive material into the body. Requirements for biological monitoring will be specified in the scheme of work and the DRPS will advise on local arrangements in each department following consultation with the RPA and Safety Services Urine Monitoring Urine monitoring may be required for anyone handling large activities of tritiated materials, especially following a spillage Thyroid Monitoring Thyroid monitoring will be required for radiation workers involved in radio iodination procedures. The thyroid concentrates iodine avidly and is therefore particularly susceptible to any ingested or inhaled radioactive iodine. The frequency of monitoring will depend on the quantities of isotope used and the number of experiments carried out. The minimum detectable dose for iodine-125 is approximately 0.2mSv dependant upon the time taken between intake and measurement. Thyroid monitoring should be done following advice and training from Safety Services. 23

24 9. Training Under IRR99, there is a legal requirement to provide training to all persons undertaking work with ionising radiations (unsealed, sealed, X-rays etc) including those with management and supervision responsibilities for the work activities. 9.1 Department Radiation Protection Supervisors All new DRPS must receive suitable and appropriate training to allow them to undertake their appointed duties. Each DRPS must attend a suitable course which is appropriate to the level of experience, departmental requirements and duties that will be undertaken by the DRPS. Training should be carried out as soon as possible and, preferably, prior to appointment. Contact Safety Services for details of suitable courses and further information. 9.2 Radiation Workers A radiation worker is anyone who works with ionising radiations from radioactive material or machines. Departments must ensure every radiation worker has received adequate and appropriate training prior to commencing work with ionising radiations. All radiation workers must complete the appropriate University online radiation training course as well as their own departmental training programme. Departments must follow a set induction programme for every new radiation worker, to be conducted by the PI/Line Manager with the assistance of the DRPS. It should be commensurate to the nature of work undertaken and the need of the individual. The following topics must be addressed: a basic introduction to radiation protection safety and personal protection requirements legal and administrative requirements departmental procedures and protocols (e.g. Departmental Local Rules) practical training and emergency procedures It is the department s responsibility to ensure that the radiation worker is competent to begin work with ionising radiation and to keep a record of all departmental training carried out. (Refer to Appendices 3 and 4 for examples of departmental ionising radiation training forms). It is expected that every radiation worker shall receive, read and understand their departmental Local Rules and registration/authorisation certificates (where appropriate) before work commences. 9.3 Safety Services Training Provision Safety Services provides various core training courses for radiation workers on a regular basis to meet the demands of registered workers. Courses include : Basic Training and Basic Practical Training for Radiation Workers This is an online training course suitable for those using unsealed sources. It covers basic concepts, biological effects, a basic introduction to radiation protection, legal and administrative requirements, responsibilities of employees and employers and practical training in restricting exposure during unsealed work, practical monitoring and record keeping. 24

25 Basic Training for Sealed Source and X-ray Workers This is an online training course covering the above topics in relation to the use of sealed sources and X-ray generating equipment. Refresher and Specialist Training (where required) At the end of each training course, radiation workers will be expected to complete a short assessment relating to the subject matter of the relevant training course. Access to online radiation training courses will be given once a completed registration form (RP8) has been received and processed by Safety Services. Safety Services provide training courses in a number of other areas which may also be beneficial to radiation workers (for example risk assessment, COSHH training etc). Please refer to the Safety Services website for details of other courses. 10. Risk Assessments The purpose of a risk assessment is to make sure that no one is injured or becomes ill as a result of work activities undertaken. The process involves finding out what aspects of the work activity could cause harm to people, then deciding if enough has been done to reduce the likelihood and severity of that harm, taking into account existing precautions. Where it is decided that further measures are required, then it should be ensured that these are implemented and remain effective. The significant findings of the risk assessment should then be recorded and provided to those who could be affected Radiation Risk Assessments and Safe Systems of Work Under IRR99, it is a legal requirement that a prior risk assessment is carried out before any new activity with ionising radiation can begin. The risk assessment must be in writing and include a system of work, which details appropriate control measures. The person responsible for carrying out the risk assessment is the PI, although guidance can be obtained from the DRPS and, if appropriate, Safety Services. The risk assessments for all new work involving ionising radiations must be sent to Safety Services for review by the RPA. Such a review must not be considered by the Head of Department or PI as approval of the project. Depending on the outcome of the risk assessment in terms of estimated potential dose, likely contamination, special procedures, etc., the area in which the work is to be carried out must be appropriately designated, i.e. controlled, supervised or non-designated. The risk assessor must consider all hazards, which may cause a radiation accident / incident to ensure the nature and magnitude of the risks to employees and others from those hazards have been evaluated. A safe working procedure (system of work) can then be produced that will assist in preventing an accident, limit the consequences of such an accident and provide employees with sufficient information, instruction and training as is necessary to restrict their exposure. A suitable and sufficient risk assessment must address all of the following matters: Departmental reference number of assessment. Date of assessment. Location and room number of laboratory. Name and status of risk assessor. 25

26 Radioisotope used activity, form, quantity. Nature of the work to be carried out. Frequency and duration of the procedure. Any persons who may be affected by the work. Example employees, students, contractors, cleaning staff, Estates Services staff and visitors. Estimated dose rates to which anyone may be exposed. The results of any previous area monitoring relevant to the proposed work. Advice from the manufacturer or supplier about the safe use and maintenance of equipment. Planned safe system of work. The extent of unrestricted access to working areas where dose rates or contamination levels are likely to be significant. Possible accident situations, their likelihood and potential severity. The consequences of all failed control measures. The risk assessment should then enable the department to determine: What action is needed to keep exposure as low as reasonably practicable? What steps are taken to achieve this control of exposure by the use of engineering controls and administrative controls? The need to alter any working conditions. An appropriate investigation level to check that exposures are being restricted as far as reasonably practicable. What maintenance and testing schedules are required? What contingency plans are necessary to address reasonably foreseeable accidents? Training needs. The need to designate specific areas as Controlled or Supervised. The actions needed to control access and implement restrictions. The responsibilities for individuals in the department for ensuring compliance with these Regulations. An appropriate programme for monitoring and auditing of risk assessments and work activities Review and Revision of Risk Assessments All prior risk assessments must be forwarded to Safety Services for RPA consultation and review. After noting any comments and following recommendations made, the DRPS will be responsible for giving departmental approval on behalf of the Head of Department. In conjunction with Regulation 7 of IRR99 and Regulation 3(3) of the MHSWR99, departments are legally required to review the risk assessment if there is reason to suspect that it is no longer valid or there has been a significant change in the work activity. Where significant changes have been made to a risk assessment, these should be forwarded for review to Safety Services. It is also good practice to review risk assessments on a regular basis (e.g. yearly), and document this process even if no changes have been made to them. 11. Radioactive Material Sources 11.1 Sealed Radioactive Sources Sealed sources are often referred to as closed sources. They may only be used in registered premises through a SEPA Registration or in line with the Exemption Order where applicable. 26

27 Sealed sources must not be brought into the University without appropriate registration. Departments must keep an inventory of all sealed sources held on the premises including details of radionuclide, activity, location and date of receipt. All sealed sources are affected by this record keeping requirement - including reference sources and those in liquid scintillation counters. It is also strongly advisable for Departments to hold a photograph of each source to aid identification; this may prove invaluable in the case of a source being moved or misplaced. All sealed sources in use must be designed in such a way as to prevent the possibility of leakage and they must not be modified in any way. Laboratories in which sealed sources are stored will be designated as Controlled or Supervised Areas as appropriate. When not in use, all sources must be kept in approved containers and securely stored in a locked store. The outside of the container must be clearly labelled with the radiation trefoil symbol with details of the radionuclide and activity. Departments must also have appropriate procedures in place for the access to such areas and to prevent unauthorised persons being able to access the sources. Sources should be visually checked on a regular basis for example, monthly. In most cases, sealed sources require to be tested for leakage every two years, but should be tested more frequently for old sources and tested immediately if any damage is suspected. Consideration must be given to the financial costs of future disposal and to the expected life span of the sources Sealed Source Marking and Certificate The sealed source should be comprehensively marked (i.e. durable and legible) by the manufacturer, tested and provided with a certificate containing the following information: Name of the manufacturer; Classification designation; Serial number of the source and the mass number and chemical symbol of the radionuclide; Nominal activity; The equivalent activity and /or radiation output in terms of fluence rate as appropriate on a specified date; The method of testing used and the rest of the test to confirm freedom of surface contamination; The method used and the result of the test for freedom from leakage. Additional information could include: For the capsule - dimensions, material, thickness and method of sealing. For the active contents chemical and physical form, dimensions and mass or volume. 27

28 Leak Tests All sealed sources require a leak test to be carried out every two years to ensure they are not damaged and spreading radioactive contamination. Inaccessible sources in liquid scintillation counters do not normally need to be tested as the operation of the machine tests the integrity of the source each time it is used. However, if under servicing conditions it is possible to access the source, then a leak test should be performed. Departments are responsible for ensuring leak testing arrangements are in place and are carried out. If a sealed source reaches the end of its recommended working life, then the frequency of testing should be increased. Leak testing may be omitted for very low activity sources, i.e, less than 1.85 kbq Unsealed Radioactive Sources Unsealed radioactive materials include sources in the form of liquids, gases, or solid powders which can give rise to a risk of external or internal contamination and may be easily dispersed. Unsealed sources in liquid form are commonly used in research establishments for radio-labelling and radiotracer research work. The use of unsealed radionuclides is restricted to authorised laboratories which are designated as Controlled or Supervised areas. (Refer also to earlier Section 6.2). General requirements which should be observed where unsealed sources are used include: Observing the principles of good hygiene and practices of good housekeeping; Covering of cuts or abrasions with waterproof dressings; Using a fume cupboard if there is any risk of releasing gas, dust, aerosols etc. Covering working surfaces with disposable absorbent material and using several degrees of containment (e.g. trays, polythene sheets, absorbent paper etc); Using appropriate shielding materials and holders; Using personal protective clothing, gloves and handling tools. 12. Radioactive Source Accountancy 12.1 Inventory of Radioactive Materials All departments should maintain an accurate and up-to-date inventory of all sources of ionising radiations (sealed and unsealed) as well as any equipment capable of producing ionising radiation Ordering of Radioactive Materials All orders for radioactive material need to be authorised (via the RP1 form) by the Principal Investigator and the DRPS before they can be ordered. Similarly, all gifts of radioactive material need to be authorised prior to acceptance from other establishments and the RP1 form should be used for this purpose also Receipt and Delivery of Radioactive Materials It is extremely important that each department receiving radioactive material has appropriate procedures in place (these should be detailed in the Departmental Local Rules or Departmental Safety Arrangements/Regulations) to ensure that there is an efficient and effective documented audit trail of the radioactive material arriving in the department. Incoming deliveries of radioactive material should not be accessible to unauthorised personnel and on no account should this material be left unattended. 28

29 All radioactive materials must be delivered to authorised University stores or identified departmental personnel. Each radioactive item ordered must be given a unique identification number on arrival (e.g. University purchase order number) and a stock record (RP5) created for it. Authorised stores and/or departmental personnel must deliver the radioactive material directly to the user or another suitable lab member and obtain a signature receipt for it. The lab recipient and/or user is then responsible for keeping track of the usage, storage and disposal of the material. The stock record must be kept-up-to-date and available for inspection at all times. The contents of radioactive packages from suppliers should be treated as being potentially contaminated. Users should unpack carefully and monitor the packaging prior to storing material Storage of Radioactive Materials It is essential that radioactive materials are stored under conditions that do not present a radiation hazard, particularly to non-radiation workers. A requirement of the Radioactive Substances Act 1993, demands that all necessary measures be taken: To prevent any unauthorised person having access to radioactive materials. That materials are securely stored in a locked store when not in use. The number of cupboards, refrigerators, or other approved places of storage should be kept to the minimum consistent with safe working. That radioactive materials are suitably shielded and stored in polythene or other suitable plastic containers. The radioactive vessels themselves should be kept in unbreakable containers. That any dedicated store area is secure, suitable and ventilated if necessary. The dose rate on the outside of the store is below 7.5 μsv/hr and if reasonably practicable, below 2.5μSv/hr. If materials are stored in fridges or freezers, there should be a designated area (e.g. shelf) for the radioactive materials only and a lock must be fitted on the cabinet. Any room, cupboard, refrigerator, or other unit used for the storage of radioactive materials, must be indicated by the International Radiation Symbol and if possible the levels of activity and the nature of the isotope so stored should be made clear. To ensure a high level of control and security is exercised at all times. To prevent sources being damaged, broken open or spilled To identify procedures to be taken to minimise the effect of any accident that may occur. If a source is set-up in an experiment or out on the bench for an experiment a warning sign should be displayed and the room must be kept locked whenever the experiment is left unattended and all appropriate personnel notified. Failure to keep radioactive materials securely stored could result in regulatory action. 29

30 12.5 Stock Records for Radioactive Materials Unsealed Sources Each unsealed radioactive source should have an individual record form that shows its usage. Each stock record should contain the following details: A unique identification reference number. Name of isotope. Chemical name. Amount of isotope (volume/weight). Activity of isotope. The activity should be recorded as the activity on the date received unless using record forms for computer entry whereby the activity on the reference date can be used. Date of delivery. Storage location. Details of all stock removed including amount, user name, remaining balance and waste disposal routes. The stock record must be completed each and every time the radioactive material is used. Details should also be written into laboratory books in case a discrepancy is discovered which requires future investigation. For every experimental technique, the radiation worker should know what proportions and categories of waste that will result from the work activity. As soon as possible after the end of each month, the DRPS is required to submit details of all radioactive waste disposed during the month to Safety Services Sealed Sources and Exemption Order Holdings Departments must retain an inventory of all sealed sources held. Recording details should include as much manufacturer s information as possible (and as specified in Section above) as well as information relating to: Date of delivery into department. Method of holding (Registration or under an Exemption Order). Storage location. Additionally, the department should perform regular, physical monthly checks on sources (e.g. monthly) and carry out routine dose rate checks. Details of these checks should be recorded and be available for inspection if required. 30

31 13. Disposal of Radioactive Waste The prime purpose of the Radioactive Substances Act 1993 is to ensure that individuals and the environment are not affected by the deliberate or accidental discharge, or disposal, of radioactive material or waste. The Scottish Environmental Protection Agency (SEPA) set out specific conditions which must be observed for the disposal of all radioactive waste Solid Radioactive Waste There are only two methods currently available for the disposal of solid radioactive waste from the University and of these only the second method is generally used 1. Disposal with ordinary waste for Very Low Level Waste (VLLW) 2. Disposal by incineration via a specialist contractor for Low Level Waste (LLW) Disposal with Ordinary Waste The Radioactive Substances Act 1993 permits small quantities of radioactive material to be disposed of with ordinary (black bag) waste under 'dustbin disposal limits'. If the activity of the waste is less than 0.4 Bq/g (or <400kBq/0.1m 3, (which is equivalent to a standard black bin bag) with no single item containing more than 40kBq then it is exempt from the requirements of RSA 1993, as it is not considered to be radioactive and thus can safely be discarded with ordinary waste. However, Safety Services must be consulted if a department wishes to dispose of waste by this route as radioactive waste disposal can be a very sensitive subject. It is essential that any signs indicating the presence of radioactive materials are removed before disposal to avoid raising unnecessary concern. A record of any VLLW disposals made through this route must be recorded and retained by departments for any waste put into refuse bins and collected by the local authority. Note there are certain conditions associated with the Exemption Order which also permits waste disposals via this method, although Safety Services should be consulted in the first instance regarding these Disposal by incineration via Authorised Waste Contractor The main route for the disposal of solid radioactive waste including radioactive clinical and scintillant waste in mini-vials is by incineration via an Authorised Specialist Waste Contractor. Solid radioactive waste is deposited into three types of segregated waste bins as follows; a) Radioactive waste containing radionuclides with a half-life of more than 90 days (e.g. H-3, C-14 etc) b) Radioactive waste containing radionuclides with a half-life of less than 90 days (e.g. P-32, P-33, I-125 etc) c) Organic scintillant waste (all radionuclide types) 31

32 Each solid waste bin container has a unique identification number allocated by the DRPS and all bags of waste material deposited into these containers must be correctly deposited into the correct type of bin and clearly marked with the following details: name of user date deposited lab number and department radioisotopes contained and activity amounts. Waste disposal records must be kept for all solid and scintillant radioactive material disposed to solid waste. Once solid waste containers are full, the bins must be sealed and the DRPS informed. The DRPS will make arrangements with Safety Services for transfer of the waste bin(s) from the laboratory area to the radioactive waste disposal store. The University is authorised to decay store some radioactive waste materials prior to removal from the premises for disposal Liquid (Water Soluble) Waste Only laboratory sinks specially designated and clearly labelled for the purpose of liquid radioactive waste can be used for the disposal of aqueous liquid radioactive waste. Under no circumstances should any disposals be made to non-designated sinks. If any doubt exists the DRPS or Safety Services must be consulted before a discharge is made. Where practicable all liquid wastes must be diluted with the appropriate carrier before disposal. In many instances this may just be water, but some compounds tend to stick to the surface of the drains, and in these cases, a carrier should be used which will help to take up the available sticking sites and prevent the occurrence of a 'hot' sink developing. Sinks should be rinsed before and immediately after the discharge. For all materials other than tritium, the sink must be monitored after disposal, and any residual activity removed if reasonably practicable. Details of all radioactive aqueous sink disposals must be recorded with: name of user date deposited sink number and department radioisotopes contained and approximate activities Departments must have arrangements in place to ensure the total amount and radionuclide type of aqueous waste disposals permitted via this route, per month, is not exceeded. If the radioactive waste exceeds or is likely to exceed the allowable disposal limit for the month, contact the DRPS or Safety Services immediately. 32

33 13.3 Gaseous Waste Any operation which is likely to produce radioactive gas, vapour or dust, must be carried out in an fume cupboard where the exhaust / discharge point has been authorised by Safety Services as an appropriate and suitably engineered system for the purpose. All proposed gaseous discharges must be cleared prior to discharge with Safety Services as strict daily and annual limits have to be complied with. Fume cupboards must always be operated with an air-flow sufficiently great to ensure the contents cannot leak back into the laboratory - normally a minimum of 0.5 m/s across the face opening is required. The sash must always be kept clear so that it can be closed in the event of an emergency. The point at which effluent air is discharged must be sited to prevent, as far as it is practicable, re-entry back into any part of any premises by way of windows, air-intakes etc. In certain cases, filters may be necessary. Safety Services will advise accordingly. It should also be noted that radioactive gas or fumes might sometimes be generated unwittingly. For instance the tritium sources used in vapour phase chromatography units will release tritium if over-heated, and the outlets from such units must always be vented to the outside atmosphere rather than into the laboratory. Similarly, it is common for some stock materials to undergo radiation decomposition resulting in the release of gaseous radioactive material. Stores where such materials are held must be suitably ventilated and vials containing any isotope which could release volatile compounds during storage should be vented in a fume cupboard before use on the open bench can be considered. This affects the use of H-3, C-14, S-35 and iodine labelled material. In certain special cases additional safety controls may be required and the advice of Safety Services should be sought. e.g. the use of glove boxes when handling powders. IMPORTANT The Radioactive Substances Act, 1993 requires the maintenance of suitable records for the discharge of any form of radioactive waste. Each and every user must ensure that such records are properly kept. Failure to do so, or to comply with the other requirements of the RSA93, could result in prosecution with penalties of fines and imprisonment. 33

34 14. Contamination Control Measures 14.1 Area Monitoring of Workplace It is the responsibility of every worker to monitor their working area and leave it in a clean and safe condition after working with radioactive material. General points: Monitor work area and any equipment before commencing work to ensure that counts are no higher than background. After completion of work with radioactive materials monitor the work area and equipment used and record this information on the laboratory contamination check record / laboratory book. These checks are important to identify areas that could have become accidentally contaminated, and to ensure these areas are free of radioactive contamination prior to the next user working in the area. The DRPS may also be expected to conduct regular monitoring of contamination to supplement the routine monitoring performed by those working in the area. Contamination checks on completion of experiment work should include: work surfaces and flooring equipment used including pipettes designated disposal sinks radiation worker (hands, body, lab coat etc) periodic checks of storage areas (typically fridges and freezers) monthly checks on floor and corridor areas outside of radiation laboratories where radiation workers may traverse in the course of their radiation activities; for example, in order to use other specialist equipment Portable Monitoring Equipment Suitable portable monitors must be available in departments to enable radiation workers to assess levels of radiation exposure and radioactive contamination. These instruments must be checked and calibrated annually through arrangements made by the DRPS. They must be kept in good operational condition and used at all times when work with ionising radiation is in progress. Any functional defect in a monitor must be reported to the DRPS immediately. An appropriate contamination monitor must be selected for the radioisotopes being used in the local area, and this must have been calibrated within the last 12 months. For the Mini Monitor range of equipment, probe E is suitable for detection of P-32, with type EL or EP15 suitable for C-14, S-35 or P-33 in addition to P-32. (See Appendix 10 for more details on monitors). Users must check the status of the contamination monitor s battery before use by turning the control knob to bat - if the needle does not remain in the green region of the scale, the batteries must be replaced. Monitoring should be carried out slowly and methodically with the probe held about 1 cm from the surface being checked for contamination. 34

35 14.3 Wipe Test Monitoring Since conventional contamination monitors are not sensitive enough to detect the low energy beta emitters such as tritium (H-3), periodic wipe-tests, requiring the use of a scintillation counter, must be performed. (Refer to Appendix 11 for an outline of this procedure). Wipe tests should be performed monthly, or once a series of experiments using tritium is complete (whichever comes sooner) Contamination Monitoring Records All radiation workers have a role to play in monitoring and in keeping satisfactory records. The monitoring requirements can vary according to the type and frequency of the work and should be detailed within Departmental Local Rules. Any guidelines given should be strictly adhered to, along with any additional instructions from the DRPS Cleaning of Glassware Contaminated glassware should be segregated and soaked in cleaning fluid before being washed in a designated sink. Radiation workers must ensure that waste materials have been disposed of and glassware decontaminated before passing to laboratory assistants for final cleaning Spillage of Radioactive Material Experience has shown that most incidents involving spills of unsealed radioactive materials do not warrant drastic action. However, before people do anything they should consider the STAR principle Stop, Think, Act, Review. After a brief assessment, measures should be taken to control the spread of further contamination. Appropriate measures may include the following: For large spills or spills involving a large amount of activity, a notice should be placed to warn other persons to keep clear of the area; the area may need to be classified as a Controlled / Supervised area and Safety Services should be informed. All incidents or accidents involving contamination of the person must be reported to Safety Services, via the DRPS. The assistance of the DRPS/PI or other nearby radiation workers should be obtained. Persons entering the affected area to carry out emergency procedures should wear appropriate PPE clothing which they should monitor and remove when they leave the area. Action should be taken to avoid the spread of contamination by marking and restricting access to the contaminated area. Contaminated personnel should be attended to first by personnel skilled in contamination control methods before any spillages are addressed. Contaminated parts of the body should be washed thoroughly but gently with soap and water until either monitoring shows that the contamination will not be significantly reduced further by this method or there is a risk of roughening or breaking the skin. Any contaminated wound, however trivial, should be irrigated with water or saline solution, care being taken to limit any spread of contamination to or from other parts of the skin. Assessment of potential dose through a wound may be required and this will be carried out through Safety Services and the RPA. 35

36 Contaminated clothing should be removed, bagged for disposal and left in or near the affected area. The spread of contamination, particularly on shoes or clothing of persons leaving the affected area, should be prevented. Persons who may be contaminated should be monitored immediately outside the area and appropriate arrangements made for their decontamination. Spillages should be cleaned from the outside in with a suitable detergent such as DECON 90 to minimise further spreading of contamination. Re-entry to the area should be restricted until radiation surveys show that the area is safe and can be reoccupied. A kit of emergency equipment suitable for use in cases of spillage should be available in departments (also available from Safety Services). Emergency kits should contain a selection of disposable protective clothing, absorbent materials, decontaminating agents, warning signs, handling tools and receptacles for contaminated articles. 15. Movement and Transport of Radioactive Materials The legal requirements regarding the transport of radioactive material are extremely comprehensive and, in some instances, complicated. It is, therefore, imperative that whenever radioactive materials, sealed or unsealed, are to be transported; they must be packaged and labelled in accordance with the relevant transport regulations. The package also needs to be accompanied with appropriate documentation. It is extremely important that each department receiving radioactive material has appropriate procedures in place (these should be detailed in the Departmental Safety Arrangements/Regulations) to ensure that there is an efficient and effective documented audit trail of the radioactive material arriving in the department. On no account should any incoming radioactive material be left unattended Movement within the University When a radiation source is being moved within University premises, for example from one laboratory to another, radioactive material should be double contained. Material must be kept inside a suitable containers or carriers which will provide adequate shielding and ensure containment of the contents in the event of damage. Surface dose rates from shielded containers should not exceed 5μSv/h when being transferred within the University or to other University buildings or stores. Great care must always be exercised to prevent spillage of any active liquid. Wherever possible unbreakable containers should be used for this purpose. If an accident should occur, immediate steps must be taken to prevent passers-by from becoming contaminated, and measures taken to decontaminate the area as soon as possible. The DRPS and Safety Services must be informed of any such occurrence Transport outside University Premises Any radioactive material to be transported to and from the University and also between departments and buildings which involve public through fares are subject to the requirements of the Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2011 (CDG2011). Very stringent requirements apply in these cases and the Regulations specify the type of package that the radioactive material can be transported in, the labelling and documentation to accompany the package and also the duties of the consignor, consignee and carrier. 36

37 Some University vehicles may be used for the transport of radioactive waste and sources of restricted activity. Public transport and taxis should not be used for transporting radioactive materials. In certain situations, advice and guidance from the RPA will be required prior to any transfer. Radioactive material must not be sent by post. Sources cannot be loaned or given to another establishment without first confirming that the receiving establishment is authorised to use the material. Separate arrangements and regulations apply to transport by rail, sea or air carrier and transport outside of the UK. Please contact the RPO for further information on any of the above. 16. X-ray Generating Equipment 16.1 Prior Authorisation (Regulation 5, IRR99) Any work involving accelerators or electrical equipment able to produce X-rays is subject to prior authorisation from the Health and Safety Executive (HSE). The HSE have issued generic authorisations (see HSE web link below) covering these practices and providing the conditions of the relevant generic authorisation can be complied with, no further action in terms of authorisation is required. If, however, the conditions cannot be complied with then the University needs to apply to the HSE on behalf of the department for an individual authorisation. Note that the use of X-rays for routine analytical work and for veterinary work are normally exempt from the requirements of prior authorisation. However for any work concerning X-ray generating equipment, DRPS must consult with Safety Services in the first instance. HSE Generic Authorisation for X-ray Equipment HSE Generic Authorisation for Accelerators 16.2 Restriction of Exposure Consideration should be given to whether the risk of ionising radiation exposure can be avoided or restricted by the following: Can an alternative technique be used, with less risk? Reduce the risk through appropriate beam filtration, effective collimation and careful choice of operating voltage and beam current. Where reasonably practicable, the work should be done in a room, enclosure, cabinet or purpose-made structure which is provided with adequate shielding. Adequate local shielding should be used as far as reasonably practicable. Shielding, including beam collimation, will normally be adequate if designed to reduce dose-rates below 7.5µSv/h. If the device is designed for use in public areas or where there is continuous access to the working area by employees or others not directly involved in the work, the shielding should be designed to reduce dose-rates to the lowest level that is reasonably practicable. In this case the dose-rate should be so low that it is unnecessary to designate the area around the device as a supervised area. In many cases, shielding will either form part of the equipment (e.g. covers, shutters and collimators) or an enclosure around the device (e.g. a room or purpose-made structure). Fluoroscopic devices should be provided with viewing facilities that do not permit direct vision of the fluoroscopy screen. 37

38 16.3 Exposure Controls The controls listed below should be implemented unless justification can be provided to and subsequently authorised by Safety Services. Interlocks or trapped key systems should be provided and properly used where they can prevent access to high dose-rate enclosures. They should be fitted so that the control system will ensure an exposure:- Cannot commence while the access door, access hatch, cover or appropriate barrier to the enclosure is open; Is interrupted if the access door, access hatch, cover or barrier is opened; and Does not recommence on the mere act of closing a door, access hatch, cover or barrier. Normally, it should be reasonably practicable to design control units for X-ray generators to prevent unintended and accidental exposure. To avoid any possible confusion: Warning Devices Control switches usually need to be labelled clearly and unambiguously. Effective interlock devices should be designed and installed in such a manner that if they fail to operate correctly no exposure can occur to individuals (failto-safe). Controls or mechanisms should be in place to prevent unauthorised or uncontrolled use of equipment. The initiation of exposures should be under key control, or by some equally effective means, so as to prevent unintended or accidental emission of a radiation beam. Where key-operated devices are provided, arrangements will be needed to ensure that keys are only available to authorised employees. Sources of ionising radiation which can give rise to significant exposure in a very short period of time should normally be fitted with suitable warning devices such as: For an X-ray generator to indicate when the tube is in a state of readiness to emit radiation and give a signal when the useful beam is about to be initiate and for a distinguishable signal when the emission is under way unless this is impracticable; For X-ray generators designed to be automatic and fail-safe, i.e. if the warning device itself fails the exposure will not proceed. The department should make sure that warning signals can be seen or heard by all those people who need to know the status of the radiation equipment for protection purposes. Automatic warning devices should be reasonably practicable for most X- ray generators. These control measures must be implemented unless justification can be provided to and subsequently authorised by Safety Services. 38

39 Maintenance of Controls All active engineering controls and design features, safety features and warning devices should be properly maintained and subjected to a regime of examination and test at suitable intervals. Maintenance means maintained in an efficient state, in efficient working order and good repair. If a failure is identified, e.g. during the examination and testing, work with the equipment must be stopped immediately and the equipment should remain out of use and until the enclosure or device is repaired and restored to efficient working order. The department should be satisfied that the person undertaking the examination or test has appropriate competence in order to ensure that the examination or test is sufficiently thorough. The frequency of tests should be annually or more frequent depending upon circumstances. The employer might consider:- The possible dose implications of a failure; The reliability of the control measure; The doses likely to be received by staff while carrying out any examination or test. Sufficient records should be kept of these examinations and tests to enable the department to identify which controls, features or devices have been examined or tested, what action is required to maintain them and when the next examination or test is due. The department should retain details such as the date and nature of the test and the name of the person carrying it out. In addition to the formal tests it is advisable to regularly carry out visual checks of all active control measures used to prevent or restrict exposure. For safety-critical features, these visual checks should be carried out on a daily basis Safe Systems of Work The engineered safety features should, so far as is reasonably practicable, be supported by written safe systems of work to be followed by employees and other people when present in the vicinity of the X-ray equipment. This may involve the issue of a permit to work that allows strict management control over the conditions in which work will proceed, how it will be done, and how it will be supervised. It is crucially important that detailed safe systems of work are produced for work on equipment in which any of the engineered safety systems have been disabled and close supervision of the work may be necessary Critical Examination by Installer/ Erector Where a person erects or installs X-ray equipment they should undertake a critical examination of the installation to ensure that:- The safety features and warning devices operate correctly; and There is sufficient protection for persons from exposure to ionising radiations. The installers or the University RPA should be consulted with regard to the nature and extent of the critical examination. The installer should provide the department with adequate information about proper use, testing and maintenance of the equipment. The critical examination may be carried out: Following erection or installation During commissioning After repair or relocation As part of trials prior to normal use 39

40 The duty to ensure that the critical examination is carried out rests with the supplier that erects or installs the equipment and not the user. This remains the case even if the critical examination is carried out, by agreement, during final trials under the supervision of the University RPA Monitoring Equipment Monitoring equipment should be available in every room where X-ray work is done, and monitoring surveys should be performed: Immediately an assembly is ready for use. After any change to an accessory or enclosure. Immediately before commencing operations that require a permit to work system to establish the position of any high dose rate areas. Periodically around equipment and enclosures to ensure that the shielding remains effective. Monitoring records should be kept of all regular and routine surveys and at other times whenever any radiation is detected which would indicate investigatory or remedial action to be taken. A record book/sheet should be kept in each laboratory where X-ray sets are used. Information should be recorded that identifies the X-ray machine, the operating conditions and any accessory used, the date of the survey and the findings of any leakage (detected in cps). One sensible approach is to incorporate the monitoring record within a log of X-ray set usage General Safety Precautions Guards (local or total enclosures) must be provided where necessary to ensure that the fingers and other parts of the body cannot be inserted into the useful beam or areas of significant scattered radiation. These guards must be either permanently fixed or interlocked to either the shutter or X-ray generator. They should be made of an appropriate material of suitable thickness to ensure that the dose rate outside the guards is kept below 7.5μSv/hr and, where reasonably practicable, below 2.5μSv/hr. In some cases it may be practicable to use an interlocked light screen or a capacitance shield as an alternative to physical barriers. A suitable beam stop of should be incorporated into an enclosure where it is possible for the primary beam to strike the wall of the enclosure. If it is necessary to move samples or other materials during irradiation, this must be done by remote control. If this is not possible and access is required to areas where the instantaneous dose rate in the beam averaged over 1 cm 2 exceeds 2.0mSv/hr, then a permit to work system should be instituted and followed (See your DRPS or contact Safety Services for guidance.) Each port or aperture of the X-ray tube housing must be provided with an automatic beam shutter so arranged that it can only be opened when the collimating system, or other apparatus providing adequate shielding, is in place. Any unused ports should be blanked off. Body monitoring badges are not required by people who only operate totally enclosed systems. All other X-ray equipment will be individually evaluated. If badges are issued these should be positioned on the body at the same height as the X-ray generators being used. If operations are being performed which require access to the open beam, then finger dosemeters should be worn if thought appropriate by the University RPA. 40

41 Clearly displayed warning light / signage is required above or in close proximity to the equipment, which should indicate when X-rays are present. This should come on automatically when the X-ray tube is energised. There should be a clear indication of whether a shutter is open or closed. This can be indicated by light emitting devices, coloured flag legends or pointers. The mains supply to the equipment must be provided with an emergency isolation switch, which should be clearly labelled. In the event of any accident or incident involving the use of X-ray sets, the DRPS and Safety Services should be informed immediately. 17. Naturally Occurring Radioactive Materials (NORM) Employers who work with materials that contain small but significant amounts of naturally occurring radioactive substances are required, under the IRR99, to take action to restrict radiation exposure of their employees and other persons who may be affected by the work with such materials and who could be exposed to an annual dose in excess of 1 msv. It is considered highly unlikely that the NORM will apply to the activities undertaken in the University, but if in doubt please contact Safety Services Radon Gas Radon is a naturally occurring radioactive gas that can seep out of the ground and build up in houses and indoor workplaces. The highest levels are usually found in underground spaces such as basements, caves and mines. High concentrations are also found in ground floor buildings because they are usually at slightly lower pressure than the surrounding atmosphere; this allows radon from the sub-soil underneath buildings to enter through cracks and gaps in the floor. Action levels have been set under IRR99 where workplace measurements are at or above 400 Bq/m 3. The University premises are not considered to be located in a radon affected area according to current geological data and the findings of some radon measurements carried out in August 2009 have confirmed this. Table 3: Radon Gas Measurements from various Buildings (May August 2009) Measured radon Location Position gas concentration (in Bq m 3 ) Figure adjusted for Winter allowance (in Bq m 3 ) Andersonian Library, Curran Building Ground <10 10 Andersonian Library, Curran Building Basement <10 20 Mailroom, McCance Building Basement <10 <10 Security Control, Livingston Tower Basement Level 4, Graham Hills Building Ground <10 <10 Boilerhouse, Jordanhill Basement Chemical & Process Engineering Lab. Ground <10 10 Weir Building Electronic and Electrical Engineering Ground <10 10 Royal College Building SIPBS, Lab 117, John Arbuthnott Building Basement

42 18. Emergency Procedures The best course of action in an emergency depends on local circumstances (see Appendix 8). An emergency could involve actual or potential dispersal of activity or exposure to a high dose rate or both but in any case safety of personnel should have priority. In emergency conditions, Safety Services acting with the Chief Operating Officer (COO), may declare a radiation emergency. During such an emergency they may close off any part of the University and halt any activity which endangers employees or the public. The COO to the University may use such facilities and services as considered necessary to resolve the emergency, also calling upon the services of DRPS, the RPA or other radiation protection services. The COO to the University, on the advice of the Safety Services and/or the RPA, will decide when to terminate the emergency and will submit a full report to Court. The RPA will normally give advice to the University through Safety Services but, if required, will advise the COO and the Statutory Advisory Committee on Safety and Occupational Health (SACSOH) directly Accidents Involving Radioactivity and Injury to the Person Any person who is suspected of having been significantly irradiated or who is injured and may be contaminated, should be taken to Glasgow Royal Infirmary, Accident and Emergency Department, 84 Castle Street, Glasgow, G4 0SF ( /4484/4314) who must be forewarned to allow preparation to be made for the receipt of the casualty to be made. A responsible person (e.g. DRPS, PI, RPO etc), who is skilled in the measurement of contamination and who is aware of the details of the incident should accompany the casualty to the hospital. The purpose of this is to demonstrate that everywhere the contaminated person has been, is free from contamination e.g. ambulance, receiving area, etc. The DRPS and Safety Services must also be informed, if not already aware of the incident Unintended Exposure An overexposure is a breach of the relevant legal dose limits to that category of radiation worker. In the event of an actual or potential overexposure to ionising radiations, the event must be reported immediately to the DRPS and to Safety Services. An investigation into the incident will be carried out afterwards. Basic actions will normally include: Make safe any equipment or operation responsible for the suspected exposure. Prevent the individual(s) concerned taking part in further work with ionising radiations. Inform Safety Services. Ensure the immediate return of any dosimeter(s) likely to assist enquiries of the events leading up to the suspected exposure. Obtain sufficient details of the events leading up to the exposure. Carry out a detailed investigation to assess the actual doses received. Unless it can be shown beyond reasonable doubt that no overexposure could have occurred Safety Services will notify forthwith: Health and Safety Executive The employer(s) of the overexposed person(s). In the case of a University employee, the appointed doctor 42

43 Accessible High Dose Rates In the event of a source giving rise to a dose rate exceeding 7.5μSv/hr in an area not already designated as a Controlled Area, the DRPS should carry out the following basic actions: Apply the STAR principle Stop, Think, Act, Review. Clear the area of all personnel. Provide local shielding if necessary and practicable and set up a barrier to mark the extent of the Controlled Area. Keep personnel out of the area and plan a means of retrieving the source in conjunction with at least one other qualified member of staff. In the event of difficulty retrieving a source, do not leave the Controlled area unmanned. Inform Safety Services. In the event of personnel exposure implement contingency arrangements for unintended exposure. Using remote means, return the source to a suitable container as soon as practicable. In the event of losing the source, implement contingency arrangements for lost sources Prepare a detailed report of the incident Spillage of Radioactive Material Refer to Section 14.6 for this Fire in Laboratories In case of fire, the normal fire drill procedures should be followed and the DRPS and Safety Services informed. If time allows, radioactive sources should be returned to shielded storage and fume cupboard ventilation switched off. When Fire Service personnel arrive, they should be advised of the significance of radiation hazard signs. Fire fighters wearing breathing apparatus can normally safely enter a Controlled or Supervised Area containing radioactive materials Physical Damage In the event of physical damage including a fire or suspected mechanical or chemical damage, to a source or its container the DRPS will: Cease to use or prevent the use of the source until it has been thoroughly examined, tested and confirmed fit for use. In the event of damaged shielding provide local shielding and store the source until alternative full shielding can be restored. Identify any Controlled / Supervised areas and set up barriers. 43

44 18.4 Missing Radioactive Substance In the event that a source is lost, stolen, mislaid or otherwise unaccounted for then the following steps must be taken: The DRPS should be notified immediately. The DRPS will use available staff and radiation monitors to conduct a search of all locations associated with the last known use of the source. If the search is not immediately successful, the DRPS will notify the Head of Department and Safety Services on the same day of the situation and the search will be extended to ensure that all possibilities for the source whereabouts are investigated. If the source is found, work must cease until a full investigation is carried out and measures are put in place to ensure that a repeat of the incident is unlikely and that the source is safe to resume using. The DRPS will make a detailed investigation and prepare a written report Notification of Certain Occurrences The University is legally required to notify appropriate enforcing authorities immediately (i.e. within 24 hours) in relation to certain occurrences. The release to atmosphere (in excess of any internal limit) or the spillage of significant quantities of material (e.g. stock bottle containing MBq quantities) must be reported to Safety Services so that an investigation can be carried out and the HSE/SEPA notified, as appropriate, if the release/spill is confirmed. Similarly if it is believed that radioactive material has been lost or stolen then Safety Services must be informed without delay, whilst the Department instigates a search and investigation. Safety Services will be responsible for notifying the authorities if a notification is required. (Refer to Appendix 12 for an extract of Schedule 8 of IRR99). 44

45 19. Key Management Actions Implementation of this Local Rule will be monitored as part of Safety Services Audit Programme, therefore the following key action points must be fulfilled where ionising radiation risks are present in a department: Subject 1 Roles & responsibilities 2 Identifying ionising radiation hazards 3 Evaluating ionising radiation risks Summary of the Key Actions Required by Departments Heads of Department must: 1. appoint in writing (RP2 Form), a responsible person (or persons as appropriate) to the role of Departmental Radiation Protection Supervisor (DRPS) to assist the HOD / Director in meeting both legislative and university requirements in relation to work with ionising radiation 2. ensure that appropriate health and safety management arrangements are put in place and implemented (where applicable) for the various aspects relating to ionising radiation work (see point 5 below). 3. ensure that these arrangements are regularly reviewed and updated where necessary 4. ensure that recommendations issued by the RPA/Safety Services following safety audit visits or if advised outwith are acted and implemented on as soon as possible. 5. ensure that any notifications (e.g. loss of source, major spillage) and/or investigations (e.g. accident, dose measurement etc) required are carried out when requested (or as appropriate) and in line with any specified time period (will depend on the issue and any potential legal requirements) Departments must: 6. identify work activities and equipment which may present an ionising radiation risk 7. carry out a prior risk assessments via consultation with the University s Radiation Protection Adviser (RPA). (See also point 4 below) 8. maintain an up-to-date inventory of radioactive materials and of ionising radiation-generating equipment Departments must: 9. work with the University in meeting all legal requirements and specifically those covered by the Ionising Radiation Regulations 1999 (IRR99) and in line with the conditions and limitations of any permits or Exemption Orders issued under the Radioactive Substances Act, 1993 (RSA93) 10. consult and seek additional advice where necessary with a RPA and supporting occupational health and safety staff 11. ensure that all areas and locations where radioactive equipment or materials are present or are used are suitably identified and appropriately designated 12. consult with Safety Services and RPA on all new proposed ionising radiation facilities, locations, projects or activities which may require advice on design features and engineering controls 4 Risk assessments Departments must: 13. ensure that prior risk assessments are carried out and 45

46 reviewed by the RPA for all new work 14. ensure risk assessments are reviewed regularly or where significant changes have occurred 15. ensure risk assessments are reviewed for new and expectant mothers, once the pregnancy has been declared in writing 5 Dept. management arrangements Departments must: 16. ensure all ionising radiation workers are registered via the RP8 form 17. ensure no radioactive substances or radiation generating equipment is brought into or removed from departmental or University premises without appropriate authorisation 18. ensure limits, conditions and reporting requirements associated with any HSE authorisation, SEPA certificates or Exemption Orders (issued under RSA93) are complied with 19. ensure suitable Local Rules are available for any areas designated under IRR99 as Controlled or Supervised areas 20. ensure all legal dose limits, dose constraints, notifications and any investigations are complied with and actioned promptly upon 21. ensure all radioactive sources, equipment and generated waste materials are safely and securely stored, and that regular physical checks are performed and documented 22. ensure accurate and detailed records are maintained and kept for all radioactive source holdings and disposals 23. ensure suitable and appropriate leak testing arrangements are in place and carried out for radioactive sealed sources and that records of these tests are kept 24. manage dosimetry arrangements for all Classified workers and any other radiation workers, where dosimetry has been identified as a requirement or issued in line with good practice 25. ensure suitable and appropriate arrangements are in place for maintenance and security staff, visitors, ionising radiation workers going to visit other establishments or coming from other establishments and for contractors and servicing engineers.in terms of access to areas, registration, dosimetry, risk assessments, induction and training 26. provide suitable and adequate numbers of monitoring instruments which is readily available for use 27. ensure monitoring equipment is maintained in good working condition, and is tested and calibrated annually. 28. ensure suitable and appropriate contamination monitoring arrangements are in place and records maintained 29. ensure radiation generating equipment, such as x-ray equipment is maintained in good condition and that regular testing and checking of engineering controls, design features, safety features and warning devices are carried out and documented 30. ensure that critical examinations are carried out when new x-ray equipment is first installed or where required under certain other circumstances (see point 16.5 of Local Rules) 31. ensure any designated areas for radiation work are suitably 46

47 and appropriately decontaminated prior to vacating the area or re-designating for other work. (Note: in some cases, notifications will be required by SEPA). 6 Information, Instruction, Supervision and Training Departments must: 32. ensure DRPSs receive appropriate and suitable training, time and support for their roles as DRPS (see for further details) 33. provide all ionising radiation workers with relevant information, instruction, supervision and training in relation to the risks and work activities involving ionising radiation 34. retain a record and details of the training provided to ionising radiation workers 47

48 20. References, Guidance and Further Reading 1. The Radioactive Substances Act 1993 HMSO ISBN The Ionising Radiation Regulations 1999 (No 3232) HMSO ISBN The Justification of Practices Involving Ionising Radiation Regulations 2004 (No. 1769) 4. Work with ionising radiation HSC. Approved Code of Practice and Guidance in support of Ionising Radiation Regulations 1999 ISBN reference L121, HSE Books 5. The Health and Safety At Work etc Act 1974 HSMO ISBN The Management of Health and Safety at Work Regulations 1999 (No. 3242) ISBN The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations The Health and Safety (Safety Signs and Signals) Regulations Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations The Radiation (Emergency Preparedness and Public Information) Regulations An introduction to radiation protection. (4th Edition) (1996). A. Martin and S.A. Harbison, Science Paperbacks ISBN Living with Radiation. National Radiological Protection Board. 4th Edition (1989). HMSO ISBN A guide to Radiation Protection in the use of X-ray optics equipment (1986). HHSC ISBN Radiation protection handbook for laboratory workers. K.J. Connor and I.S. McLintock. HHSC ISBN X. 15. The Radioactive Substances Exemption (Scotland) Order HSE Ionising Radiation Protection Information Sheets Sheet No. 2 - Radiation doses - assessment and recording Sheet No. 4 - Protection of outside workers against ionising radiation Sheet No. 5 - Prior authorisation under IRR99 Sheet No. 6 - Radiation Protection Supervisors Sheet No. 7 - Selection, use and maintenance of portable monitoring Instruments Sheet No. 8 - Control of radioactive substances Working safely with ionising radiation : guidelines for expectant or breastfeeding mothers (INDG 334) Appropriate designation of classified persons Wear your dosemeter 17. Health Protection Agency Ionising Radiation Information (from HPA Website) Doses from Discharges Radon and Radon in Dwellings Scotland 2008: Review and Atlas Transport of Radioactive Materials 18. Association of University Radiation Protection Officers (AURPO) Guidance Notes Work with Ionising Radiations in Research and Teaching, Dec 2010 Transport of Radioactive Materials by Road, 2010 Guidance Note No.6 48

49 Appendix 1 University Safety Management Responsibilities Figure 1: Occupational Health & Safety Management Responsibilities OHS Management Responsibility Key Roles University Court Principal Executive Team Chief Operating Officer Faculty / Professional Services Chief Operating Officer Chief Financial Officer Deans Departments/ Schools Directors / Heads Managers Principle Investigators Academic Supervisors All staff Figure 2: Overview of Occupational Health & Safety Planning and Review Structure OHS Planning & Review Structure Key Roles University Court Principal Executive Team Chief Operating Officer Chief Financial Officer Statutory Advisory Committee on Safety and Occupational Health (SACSOH) Departmental Safety Committee Deans Senior Officers Safety Services Directors / Heads Managers Principle Investigators Academic Supervisors All staff 49

50 Appendix 2 Guidelines for Commencing Work with Radioactive Materials Research Worker or Student Member of Staff Consult project supervisor about the scope of the work activity Meet the DRPS to discuss the following aspects of the work: 1. Where the work will be carried out 2. Check whether the radionuclides(s) and quantities are within the Dept. SEPA allowance 3. Check that there is an appropriate SEPA Authorisation for disposal of the radionuclide(s)/ quantity and for the route of disposal. Does the radionuclide(s) and quantity to be used in the work comply with the existing SEPA Registration and Authorisation? YES NO Have you worked with Ionising radiation before? YES Are you or have you previously been a classified worker? If the project EXCEEDS the SEPA & Dept. limits for Registration and Authorisation, then the work CANNOT proceed and you MUST consult the RPO NO YES Complete RP8 registration form & pass to DRPS Contact the DRPS & RPO with details of past employment & dose history Complete basic online radiation training course and departmental training. Risk assessments / systems of work. Any new work (or major changes to existing work) requires to be sent to the University Radiation Protection Adviser for consultation and approval BEFORE work can begin. If deemed necessary (or if required), appropriate dosimetry will be supplied to the worker by the DRPS Training in departmental procedures for handling, using and disposal of radionuclide(s) will be provided locally. Workers should familiarise themselves with the University Local Rules for work with Ionising Radiation The University undertakes an annual review of all Departments using radioactive materials 50

51 Appendix 3 Guidelines for Commencing Work with X-ray Generating Equipment Research Worker or Student Member of Staff Consult project supervisor about the scope of the work activity Meet the DRPS to discuss the following aspects of the work: 1. Where the work will be carried out; 2. The equipment that will be used; 3. The procedures that will be carried out using the equipment Check the X-ray equipment complies with the Health & Safety Executives Prior Authorisation for the use of Electrical Equipment Intended to Produce X-rays (see web link in section 16.1) YES NO Have you worked with Ionising radiation before? YES Are you or have you previously been a classified worker? If NO, then the work CANNOT proceed and you MUST consult the RPO NO YES Complete RP8 registration form & pass to DRPS Contact the DRPS & RPO with details of past employment & dose history Complete basic online radiation training course for x-rays and departmental training. Risk assessments / systems of work. Any new work (or major changes to existing work) requires to be sent to the University Radiation Protection Adviser for consultation and approval BEFORE work can begin. If deemed necessary (or if required), appropriate dosimetry will be supplied to the worker by the DRPS Training in departmental procedures for the use of X-ray equipment will be provided locally. Workers should familiarise themselves with the University Local Rules for work with Ionising Radiation The University undertakes an annual review of all Departments using X-ray generating equipment 51

52 Appendix 4 Abbreviated Departmental Local Rules for Radiological Designated Areas A A01 A02 A03 A04 A05 A06 A07 A08 A09 A10 A11 A12 A13 B B01 B02 C C01 C02 SAFETY MANAGEMENT ARRANGEMENTS While in the Department, adhere to instructions displayed on any additional Local Rules, Contingency Plans and signage. All persons entering the Controlled / Supervised Area must wear a TLD badge and a laboratory coat as appropriate to the area. Additional dosimetry or Personal Protective Equipment (PPE) may be specified in Local Rules, Permits to Work, Method Statements or instructions specific to other areas of the Department and /or building. Ensure that you are aware of the correct usage of PPE and immediately report any defects to the DRPS. TLD badges (and finger dosemeters if appropriate) must be safely stored at the end of each work period and returned to the DRPS at the end of the quarterly (or other) issue period for processing. All persons entering a Controlled Area must be a Classified Person (registered with the Approved Dosimetry Service) or have an approved Written Arrangement. External Classified / Registered Radiation Workers must have sought advice from the Radiation Protection Adviser (RPA) and DRPS prior to entry into a Controlled / Supervised Area. Pregnant women and nursing mothers must not enter Controlled / Supervised Areas unless authorised to do so by their line manager, the RPA and Occupational Health. Those workers must have a specific Written Arrangement prior to entry into Controlled / Supervised Areas. All visitors to the Controlled / Supervised Area must report to the Departmental Radiation Protection Supervisor (DRPS). DRPS names are posted below and in the Departmental Local Rules. Any maintenance or testing of engineering controls, safety features or warning devices must be carried out under approved instructions or a Permit to Work, clearly displayed in the working area. All persons working within the Controlled / Supervised Area must have completed appropriate and suitable training in the specific arrangements for the lab / department / building (including alarms and emergency arrangements) or be escorted by DRPS or other appropriate personnel. No person may enter the Controlled / Supervised Area if they have open wounds, cuts, body piercing or skin conditions. Advice must be sought from the RPA and / or the Occupational Health Physician to arrange alternative arrangements. In agreement with the DRPS, all persons must minimise the amount of equipment taken into the Controlled / Supervised Area All persons must ensure that any equipment being removed from the Controlled / Supervised Area should be monitored and issued with a Contamination Clearance Certificate, following departmental procedures. No radioactive waste may be removed from the laboratory / store area / building unless arranged and authorised by the DRPS for the relevant area or the University Radiation Protection Officer (RPO). No eating, chewing, drinking, smoking or similar activity may take place within any laboratory or Controlled / Supervised Area. ALARP ARRANGEMENTS All staff must ensure that radiation exposure is kept as low as reasonably practicable (ALARP). The DRPS must aim to ensure that no persons working within their area of responsibility exceed the University s whole body or extremity dose quarter period Investigation Level of 0.1mSv in a 13-week period. An annual review of doses will also be performed. ENTRY AND EXIT FROM CONTROLLED / SUPERVISED AREAS Entry: Collect laboratory coat and ensure that you are wearing your TLD badge and any additional Dosimetry / PPE specified under Written Arrangements If not your normal place of work or you are working under Written Arrangements, report to the DRPS upon arrival for entry. Exit: If not your normal place of work or you are working under Written Arrangements, inform DRPS of intent to exit the area and follow any local departmental procedures Check for personal contamination prior to leaving the area (use monitor to check hands, feet etc.) If contamination detected, follow Contingency Plan in University Local Rules (Section 14.6) or other specified / appropriate documentation (e.g. Dept. Local Rules, Dept. Safety Regulations, specific risk assessment or safe system of work ) Ensure that you wash your hands prior to leaving the area. D D01 D02 RADIOLOGICAL SAFETY CONTACTS DRPS - [Department names and contact numbers to be inserted here] Other - [Relevant Department contact with details to be inserted here] D03 University Radiation Protection Officer, Safety Services or Ext D04 Radiation Protection Advisor Accessed via Safety Services on Ext (or through Security Control on Emergency Ext. No or General Ext number. 3333) D04 Outside normal working hours contact Security Control on Emergency Ext. number 2222 (or General ext. Number 3333) Endorsed by : Authorised by : Signature Name Date RPA DRPS 52

53 Appendix 5 Written Arrangements for entry to Controlled Areas Written Arrangements (WA) for Entry into Radiologically Controlled Areas (RCA s) Declaration for entry to RCA s for hands-on work or for external Classified Workers External classified workers are defined as classified radiation workers who are not covered by the University Approved Dosimetry Service By signing these Written Arrangements I declare the following; I agree to abide by all conditions stated within the Written Arrangements overleaf covering Entry into Controlled Areas I agree to abide by any additional requirements stated below. I declare that I am not a Classified Radiation Worker under Ionising Radiations Regulations 1999 or, if I am classified radiation worker, I will provide my Radiation Passbook (or equivalent) to Safety Services prior to entering the RCA. Purpose of visit to RCA location, duration and type of work Additional Requirements (Supervisor / DRPS): Additional Requirements and dose limits (Safety Services): Supervisors name: Supervisors signature / date / telephone number: Visitors name and employer: Visitors signature / date: Visitors date of birth: Expiry date for WA: Visitors National Insurance number: RPO name (Safety Services): RPO Signature / date / telephone number: 53

54 Appendix 5 Written Arrangements for entry to Controlled Areas Written Arrangements for Entry into Radiologically Controlled Areas SCOPE: All persons entering a Radiologically Controlled Area to carry out work must be a Classified Person (registered with the Approved Dosimetry Service at the University) or have an appropriate Written Arrangement. External Classified / Registered Radiation Workers must have sought advice from Safety Services prior to entry into the Controlled Area. These written arrangements are required by the Ionising Radiations Regulations 1999 (Reg.18.2&18.5). Short duration visitors who are only present for observation purposes do not need to sign the Written Arrangement, although they must be made familiar with Local Rules and emergency arrangements. Supervisors RESPONSIBILITIES You must read and implement these written arrangements before the person can enter a Controlled Area to carry out work. You must ensure that the person has received proper instruction; training & information to enable them to discharge their responsibilities (see personal responsibilities below). You must demonstrate all of the necessary techniques required to carry out the work, in a safe and efficient manner, in conjunction with the DRPS You must ensure that the persons whole body and extremity dose does not exceed the site dose limits, in conjunction with the DRPS and Safety Services You must provide supervision of the person in the Radiologically Controlled Area You must provide suitable PPE as recommended for the area, in conjunction with advice from the DRPS You must ensure the correct disposal routes of in-active/active waste, in conjunction with the DRPS. You must return dosimetry at the end of the work period Personal RESPONSIBILITIES While in the area, you must adhere to instructions displayed on any additional Local Rules, Contingency Plans and signage You must wear your body dosimeter at all times in Controlled Areas and must not enter a Controlled Area without dosimetry. Body Dosimeters must be returned to your Supervisor upon completion of the visit. Declared pregnant women and nursing mothers must not enter Controlled Areas unless authorised to do so by their Supervisor, the RPA and Occupational Health. Those workers must have a specific Written Arrangement prior to entry into Controlled Areas. All persons working within the Controlled Area must have completed training in the specific arrangements for the area (including alarms and emergency arrangements) or be escorted by a suitably qualified and experienced University employee. You must report any accidents or near misses to the supervisor, DRPS and log it in the appropriate accident book No person may enter the Controlled Area if they have open wounds, cuts, recent body piercing / tattoos or skin conditions without obtaining prior advice from Occupational Health and Safety Services. In agreement with the DRPS, all persons must minimise the amount of equipment taken into the Controlled Area. All persons must ensure that any equipment being removed from the Controlled Area should be monitored by a suitably qualified and experienced person No waste may be removed from the area unless authorised by the DRPS for the relevant area. No eating, chewing, drinking, smoking or similar activity may take place within the Controlled Area. General Entry to Controlled Areas (specific instructions may also be provided locally): o Collect laboratory coat and ensure that you are wearing your body dosimeter and any additional Dosimetry / PPE specified under Written Arrangements If not your normal place of work or you are working under Written Arrangements, report to an DRPS upon entry o General Exit from Controlled Areas (specific instructions may also be provided locally):: o If not your normal place of work or you are working under Written Arrangements, inform DRPS of intent to exit the area and follow any local barrier procedures o Utilise the frisking probe / monitors (where present) to check for contamination o If contamination detected, follow Local Rules / Contingency Plans, in conjunction with the DRPS Exit, ensuring that you wash your hands. o 54

55 Appendix 6 Example Record of Departmental Training In the Procedures for Working with Unsealed Radioactive Materials Name of Radiation Worker: Safe System of Work Number: Department: Laboratory: PROCEDURES Self instruction (List and detail as appropriate) Computer Radiation Software For example: The new worker should work through a Departmental radiation software package to understand the biological effects of radiation and safety issues Relevant System of Work I have read and understood the relevant System of Work Training given by the PI / DRPS or other suitable and experienced Radiation Worker as designated by the PI Awareness of the certificates under The Radioactive Substances Act Show the certificates to the new worker and explain their importance. University and Departmental Local Rules Go through all relevant sections of the University and Departmental Local Rules with the new worker. System of work Go through system of work to be used. Organisation of work area in the laboratory Show where the work is to be done and procedures to minimise contamination and exposure. Labelling of work area. Controlled / Supervised area (where relevant). Ordering and receiving of radioisotopes Explain the procedures for ordering new stock and receiving it into the laboratory. Holding limit for laboratory (if applicable). Storage of radioisotopes Show the storage location in the laboratory and explain security measures. Stock record Demonstrate procedure for recording stock withdrawal on computer database or paper record system and procedure for correcting any errors. Disposal of waste Demonstrate how waste is disposed of and explain how to record waste disposal on computer database (e.g. SPIDER) or paper record system. Waste disposal limits for laboratory. Contamination monitoring Explain use of mini-monitor, swabbing of work area, and recording in contamination monitoring book. Contingency planning and emergency procedures. Personal dosimetry (if relevant) Explain purpose of personal dosimetry, organisation, correct use and safekeeping of dosemeters. Practical instruction and practice Dilution and aliquotting of stock radioisotopes. Manipulations required for the particular Safe System of Work and counting samples generated. Contingency planning and emergency procedures. Practice run in the absence of radioactivity Other training required by the Principal Investigator (specify) TRAINING GIVEN BY (SIGNATURE) DATE Check of accuracy of record keeping Check of the stock and waste records after the radiation worker has commenced radiation work. Level of supervision required: I have received the above training (signature of radiation worker and date) 55

56 Appendix 7 Example Record of Departmental Training In the Procedures for Working with X-Ray Generating Equipment Name of Radiation Worker: Department: Laboratory: Safe System of Work Number: PROCEDURES Self Instruction (List and detail as appropriate) Computer Radiation Software For example: The new worker should work through a Departmental radiation software package to understand the biological effects of radiation and safety issues Relevant Safe System of Work I have read and understood the relevant Safe System of Work Training given by the PI / DRPS or other suitable and experienced Radiation Worker as designated by the PI University and Departmental Local Rules Go through all relevant sections of the University and Departmental Local Rules with new worker. Safe System of work Go through safe system of work to be used. Operational Training Warning & Safety Devices Go through the various radiation warning and safety devices (eg. warning signs, emergency stop, interlocks etc.) incorporated into each piece of X-ray producing equipment. Operating Procedures Go through the written operating procedures for equipment including: a) Sample insertion and manipulation b) Equipment alignment c) Routine maintenance d) Data recording procedures Observation of complete procedure carried out by experienced user Personnel Exposure Monitoring Explain when this would be required e.g. during maintenance by suitable qualified personnel only. Radiation Surveys Go through when these should be carried out, what the survey involves, how to carry it out and where to record the results. Security Go through security measures which ensures equipment cannot be used by untrained or unauthorised personnel. Emergency Procedures Go through emergency procedures for overexposure, equipment malfunction or failure etc. University Safety Services Training X-ray users to attend next available training course. Other training required by the Principal Investigator TRAINING GIVEN BY (SIGNATURE) DATE Level of supervision required: I have received the above training (signature of X-ray radiation worker and date) 56

57 Appendix 8 Contingency Plan Contingency Plan Room [Insert room number here] GENERAL This document provides a summary of the Contingency Plans required for the above area, in accordance with the Ionising Radiations Regulations 1999, and provides basic information on what actions to take in the event of specific reasonably foreseeable accident scenario s occurring in the building. The scenario s have been identified through the output of risk assessments for operations and forms a sub-set of the Local Rules. The Contingency Plan must be read, understood and followed by all staff entering the room. CONTINGENCY PLAN EVENT HOW WOULD YOU KNOW? ACTION TO TAKE Fire / explosion Serious medical emergency / personal injury Fire alarm sounding (continuous note) Visible fire or explosion Stop work immediately Initiate the fire alarm (break glass) if not already sounding Dial 2222 (Security Control) and confirm details of the event Evacuate building to designated assembly point Await further instruction Call 2222 (Security Control), requesting an Ambulance, Occupational Health and / or a First Aider as required to attend the scene Ventilation failure (room) Building ventilation alarm sounds Stop work immediately Exit the room in a safe manner and close door. Report to Supervisor and DRPS Await further instruction Ventilation failure (plant / local) Plant ventilation alarm sounds Indicated by manual measurements Stop work immediately Warn other staff and exit room in a safe manner, closing door. Restrict access to the room Inform supervisor and DRPS Await further instruction Radioactive or chemical spill (in plant or containment) Observed spillage of liquid, dust or powder in plant Dropped sample, container or vessel in plant Visual identification of previous spillage Stop work immediately Inform supervisor and DRPS Follow any instructions from the supervisor, DRPS or Safety Services Radioactive or chemical spill (outside plant or containment) Observed spillage of liquid, dust or powder Dropped sample, container or vessel Local contamination surveys Stop work immediately Take several steps backwards to a safe position Shout to other staff and request assistance Restrict access to the affected area Inform supervisor and DRPS Follow any instructions from the supervisor, DRPS or Safety Services High radiation dose rate where not expected Routine dose rate measurements Stop work immediately Warn other staff and evacuate to a safe place Restrict access to the affected area Inform supervisor and DRPS Follow any instructions from the supervisor, DRPS or Safety Services Personal contamination (skin / hair/ clothing / lab coat / overshoes / other) Wound sustained in Controlled Area Detected during self monitoring (hand held probes, frisking probes) You have just cut, pricked or grazed yourself Stop work Inform your supervisor and DRPS Follow any instructions from supervisor, DRPS or Safety Services Stop work Inform your supervisor and DRPS Follow any instructions from supervisor, DRPS or Safety Services 57

58 Contamination monitors (G-M tubes) Appendix 9 Radiation Monitors - Summary of Series 900 Mini Monitors Used for surface contamination detection either bench or personal (unsealed work or leaking sealed sources). 900 series E, general-purpose thin end window G-M tube, suitable for soft emitters. Under certain conditions surface and dose rates may be estimated. 900 series EP15, similar to E but with a large end window halogen quenched G-M tube. More sensitive then E but a lower scale limit recommended for lower contamination limits of soft emitters. 900 series SL, side window G- tube, suitable for monitoring hard and contaminants (S type is similar but shorter tube and 1/2 the sensitivity) 900 series EP15F, similar to EP 15 but designed for industrial use. 900 series EL, older design quenched G-M tube, superseded by EP15. MINI 900 Type EP15 Probe Mini 900 with Type EL probe MINI 5.10 Type E Probe Dose rate monitors Used to monitor dose rates when dealing with high activities of unsealed material, sealed sources. 900 series type compensated G-M tube, range 0.5 to 5000 Sv h -1, useful response from 45keV to 1.5MeV, not recommended for monitoring X-radiation from apparatus operating below 75keV. 900 series type G, for environmental use; scale 0.05 to 75 Sv h -1, useful energy range is 55keV to 1.5MeV and above, not suitable for monitoring x- radiation. 900 series type D, partially compensated G-M tube, range 0.5 to 1000 Sv h -1, useful energy range is 30keV to 1.5MeV but response maintained down to 17keV, suitable for measuring radiation from X-ray apparatus operating at or above 45keV. 900 series type X, end window G-M tube (no energy compensation), scale 0.5 to 2000 counts, sensitive down to 10keV therefore useful for locating X-ray leakage from a variety of system including high voltage equipment where X-rays are generated adventitiously, not intended for measurement but a check device. 58

59 Appendix 9 Radiation Monitors - Summary of Series 900 Mini Monitors Mini 900 with R Type Probe Mini 900 with Type D Probe Mini 900D with H (10) probe Contamination/dose monitors (Scintillation) Gamma scintillation probe type 41, Na iodide crystal, with lead surround, suitable for energies of 25keV upward, sensitivity 10 Sv h -1. Gamma scintillation probe type 41S, similar to Type 41 but with a larger crystal for increased sensitivity and without the shielding, suitable for energies of 25keV upward, sensitivity 10 Sv h -1, omni-directional, suitable for medium and high energy gamma radiation. Gamma scintillation probe type 44A, sodium iodide crystal, suitable for energies ranging 15keV to 250keV, it is also sensitive for energies above 500keV, aluminium window. Gamma scintillation probe type 44B, beryllium window version of Type 44A, sensitivity extended down to 5keV, useful for Fe-55. X-ray scintillation probe type 42A, sodium iodide crystal, aluminium window, higher sensitivity then Type 41 for energies below 60keV to a minimum of 10-15keV, an integral lead collimator makes it useful for I-125 monitoring. X-ray scintillation probe type 42B, a beryllium window version of Type 42A detects very low energies down to5 kev, response above 15keV is almost identical to 42A. MINI A Probe 59