- RSO Audits
The RSO audits PHs at frequencies determined by the radionuclides and maximum activities used in experiments. Items of noncompliance are reported to the PH. The frequency of lab audits may be affected by the violations/areas of concern noted (i.e., the RSO may audit more frequently when a PH receives certain violations). The RSO's audit includes, but is not limited to, the following:
- confirming that training requirements have been met for radionuclide and non-radionuclide users
- ensuring that labs used for radioactive material work are approved
- confirming that this manual and the Radionuclide Inventory and Survey Book are available
- confirming that direct and/or contamination surveys are complete and that all contaminated areas have been decontaminated and resurveyed
- checking to see that radionuclide inventory is up-to-date
- verifying that survey meters are calibrated, available, and in working order
- confirming that all postings are in place (e.g., NRC 3, labels, signs, etc.)
- determining if there is eating, drinking, smoking, application of cosmetics, and/or storage of consumables in the lab
- ensuring that all radioactive material is secure (i.e., lab or radioactive material is locked or attended)
- performing a direct and contamination (wipe) survey, as appropriate (If a contaminated wipe is found by the RSO, the PH will be notified and is responsible for decontaminating and resurveying the area.)
- Violations and Areas of Concern
As stipulated in the University's NRC license application, the RSC, in conjunction with the RRSC, has the responsibility to verify that all regulations, policies, and procedures (i.e., the radiation safety program) relating to the use of radioactive material at this institution are followed. Therefore, a policy has been established to provide guidance to the RSO when dealing with situations where deviations from the radiation safety program occur. This policy also serves to notify PHs of what action is to be expected when such deviations are noted in areas and procedures under their control. The aforementioned deviations have been divided into two distinct categories. One category includes deviations which have greater health and safety and/or regulatory significance. Deviations in this category are termed "violations." The second category includes deviations of lesser health and safety and/or regulatory significance. Deviations in this category are termed "areas of concern." Implementation of this policy is as follows:
Violations involving radiation exposures (or the potential for same) which are likely to pose immediate health hazards and/or exceed regulatory limits:
The RSO will immediately suspend any procedures which may result in such violations/hazards. The Chairmen of the RSC and RRSC will be notified as soon as possible of such action. Regardless of the reason for such action, no procedures using radioactive material may be resumed until two conditions are met. First, the PH shall submit a written report to the RSO outlining the cause of the violation/hazard (or the potential for same) and the corrective action implemented to prevent future violations/hazards. Secondly, once the cause of the violation/hazard is identified, it can be assured that the resumption of the procedures will not cause any additional violation/hazard. The decision to resume procedures involving radioactive material may be made by the Chairman of the RRSC and the RSO acting as an executive body. A special meeting of the RRSC and/or the RSC may be called at the discretion of the respective chairmen. A full report will be sent by the RSO to the RRSC members within two weeks of the incident and will be included on the agenda of the next quarterly meeting. This report will also be provided to the RSC members and included as an agenda item at the next RSC meeting.
Less severe violations and areas of concern:
Violations and/or areas of concern which do not fit the aforementioned criteria are monitored for the duration of a permit (a period of one year for new permits, then every two years thereafter). When the permit is renewed, any previously cited violations/areas of concern are nullified; however, the permit may be renewed on a probationary basis at the discretion of the RRSC. In certain instances, the RSO may increase the frequency of its audits. The policy is based on a point system with a "violation" equivalent to two points and an "area of concern" equivalent to one point. The following is the description of action to be taken by the RSO and the PH when a certain number of points is reached or exceeded:
- The RSO will notify the PH in writing of the violations and/or areas of concern. This notice will provide adequate detail to assure the PH is aware of circumstances resulting in the written notice.
- The PH must always respond in writing to the RSO's notice regarding the violation/area of concern within a period of 10 working days unless alternate directives are spelled out in the notice. This response must include the reason for the violation/area of concern and what measures are to be implemented to prevent the recurrence.
- When four points are accumulated on a permit, a copy of the written notice sent to the PH will also be sent to the RRSC Chairman and the PH's department chairman.
- When a total of six points is reached, a copy of the written notice sent to the PH will also be sent to the RRSC Chairman and the PH's department chairman. In addition, no radioactive material may be received (including transfers) by the PH until the circumstances which lead up to the suspension of radioactive material receipt can be reviewed by the RRSC. The PH may request a meeting with the RSO and the RRSC Chairman to request temporary re-establishment of radionuclide receipt privileges until the RRSC is able to meet. This temporary re-establishment of radionuclide receipt will be at the discretion of the RRSC Chairman and the RSO.
- Should additional violations or areas of concern occur following the aforementioned actions, written notices will be sent as previously stated. The PH will not be allowed to receive radioactive material (including transfers) until he/she meets with a sub-committee of the RRSC established to review the PH=s compliance history and any corrective actions proposed by the PH. This sub-committee consists of the Chairman of the RRSC, the RSO, and members of the RRSC. This sub-committee will decide if radionuclide receipt and use will be allowed to continue based on the compliance history and any corrective actions proposed by the PH. Actions of the PH and the sub-committee will be reviewed at the next RRSC meeting.
- The total number of points and subsequent actions taken for PHs with multiple permits may be considered separately or collectively at the discretion of the RSO and/or the RRSC. This discretion will be based upon factors including the similarities among various violations/areas of concern, the locations of authorized use, the types of violations/areas of concern, and any other relevant information.
- During the RRSC reviews mentioned above, the RRSC will evaluate the compliance history of the PH, the corrective actions which have been proposed or implemented, and the recommendations of the RSO. Based upon their review, the RRSC may elect to cancel the permit, allow activities under the permit to continue (with or without additional restrictions), require increased surveillance of the PH's activities by the RSO, and/or take any other actions deemed appropriate for the circumstances.
Examples of common violations and areas of concern are listed below. This list is not all inclusive, but simply serves to illustrate the more common violations and areas of concern.
- failure to perform 2 or more contamination (wipe) surveys at the required frequency
- failure to perform 2 or more direct radiation surveys at the required frequency
- failure to perform decontamination procedures when significant contamination levels (greater than 200 cpm/100 cm2) were detected by the laboratory
- eating, drinking, smoking, storing consumables, and/or the applying cosmetics in a radionuclide laboratory
- improper labeling of radioactive waste and/or improper storage of radioactive waste
- utilization of a lab for radionuclide use without appropriate authorization by the RSO/RRSC
- utilization of laboratory procedures which could potentially expose personnel to unnecessary radiation hazards
- failure to utilize measures to prevent personal contamination
- utilization of radioactive material by individuals who are neither fully authorized nor have received temporary authorization by the RSO
- failure to report significant radiation accidents to the RSO
- performance of procedures which are neither specifically authorized on the PH's permit nor have been reviewed and temporarily approved by the RSO
- failure to comply with special restrictions spelled out on the PH's Radionuclide Use Permit
- Areas of Concern
- incomplete documentation of contamination or direct radiation surveys
- failure to perform one contamination (wipe) survey at the required frequency
- failure to perform one direct radiation survey at the required frequency
- failure to maintain adequate inventory records
- failure to maintain up-to-date posted documents
- poor laboratory housekeeping practices
- failure to follow radioactive waste procedures
- failure to provide adequate measures to prevent the unauthorized removal of radioactive material
- transfer of radioactive material between PHs without proper notification to the RSO
- transfer of radioactive material to a PH who was not authorized for the material
- failure to follow iodination procedures
- failure to utilize required personnel monitoring devices
- failure to comply with bioassay requirements
- significant contamination levels measured by the RSO
- failure to comply with requirements for the use of radioactive material in animals