Radiation and laser safety procedure

Intent

The purpose of this procedure is to protect the health and safety of people and the environment from the harmful effects of radiation. The Procedure addresses public, occupational, and environmental aspects of radiation practices and provides a cohesive framework of controls consistent with national and international requirements for optimised health and environmental protection.

Scope

RMIT University – wide procedure

Exclusions

None

Procedure steps and actions

1. Responsibility

Human Resources

  • Oversee radiation safety in the University
  • Annual Audit of all Radiation / Laser sources at RMIT – documents, records and reports
  • Assist and advise schools on radiation safety
  • Coordinate and assist with implementing safety policies and procedures
  • Receive and review personal monitoring results and keep records of these
  • Assist with waste management and disposal
  • Receive notification from schools of the intention to purchase radioactive sources or equipment
  • Assist with workplace monitoring
  • Establish and monitor Radiation / Laser Safety Committee (R/LSC)
  • Receive completed Project Notification forms from schools
  • Coordinate registration / licensing required by Dept Human Services (DHS) including:
    • Advise of University contact person / Radiation Safety Officer (RSO)
    • University Management License
      • Sealed sources
      • Unsealed sources
      • Irradiating apparatus
      • License for research with human volunteers
    • Licensing of radiation operators
  • Advise DHS of the following:
    • Immediately
      • Loss or theft of radiation apparatus / source
      • Person received dose > 1mSv unexpectedly
      • Radiation source is or has been out of control
      • Radiation source damaged or malfunctioning
      • Accidental release of radioactive material
      • Surface significantly contaminated with radioactive substance
    • Within 5 working days
      • High personal monitoring reading
      • Incorrect medical procedure
      • Minor accidents
  • Coordinate requirements of Australian Safeguards and Non Proliferation Office (ASNO)
    • Advise of University contact person / RSO
    • Report all transactions / losses of radioactive materials or security incidents as soon as they occur
    • Report an inventory of radioactive materials annually
    • Advise of any changes to buildings at an approved facility, annually
  • Facilitate inspection by the International Atomic Energy Agency (IAEA) where required
  • Emergency Procedures Manifest is to contain all radiation source locations.

The Head of School

  • Their school complies with legislative requirements and University policies / procedures
  • A safe work place is provided and maintained
  • All persons working with radiation are provided with a suitable level of information, training, instruction and supervision to allow them to do their work safely
  • Risk controls are implemented and maintained, to minimise the risks posed by radiation
  • Consultation with staff on arrangements for ensuring radiation safety occurs, including involvement of the relevant OHS Representative(s)
  • Radiation safety procedures which are specific to the school are developed, implemented and regularly reviewed
  • The school has an appropriately competent and resourced RSO and/or Laser Safety Officer (LSO). These positions are nominated by the Head of School
  • Maintain communication between the School and Human Resources
  • Staff and students working with radiation are to be adequately supervised.

School Radiation Safety Officer (RSO)

  • Monitoring work practices to ensure safe systems of work are being followed
  • Ensure Radiation Dosimeters are sent away for analysis – monitor results – report immediately to Human Resources any readings above 20mSv
  • Ensuring the implementation and regular review of radiation monitoring and control procedures within the school
  • Coordinate personal monitoring program for radiation workers
  • Ensuring immediate action is taken in the event of unsafe practices, accidents or emergencies
  • Liaising with Human Resources on matters involving radiation safety, monitoring and control procedures within the school and informing Human Resources of any alterations to the workplace and radiation inventory affecting licenses and registrations
  • Report all accidents, incidents and near misses
  • Informing Human Resources and the area Health & Safety Representative (HSR) of any accident or incident involving radiation in the school or proposed changes in the school involving radiation that may affect the health or safety of any person working in or visiting the area
  • Advise on training requirements for people working with radiation
  • RSO names/school notification & training forwarded to Human Resources listed on intranet
  • Participate on R/LSC

Laser Safety Officer (LSO)

  • Monitoring work practices to ensure safe systems of work are being followed
  • Reporting all accidents, incidents, hazards and near misses
  • The appropriate training and instruction of each operator of a laser installation
  • Ensuring the wearing of laser protective eyewear and protective clothing by each operator of a class 3 or 4 laser at all times as stated in Personal Protective Equipment (PPE) Guideline
  • The posting of appropriate warning signs at entrances to rooms housing lasers
  • Liaising with Human Resources on all of the above matters and informing of any laboratory changes which may affect laser operation
  • Ensuring immediate action is taken in the event of unsafe practices, accidents or emergencies
  • Informing the area HSR of any accident or incident involving lasers in the school or proposed changes in the school involving lasers that may affect the health or safety of any person working in or visiting the area
  • Advise on training requirements for people working with lasers
  • LSO names/school listed on intranet

Staff and students designated as radiation workers

Designated Radiation Workers are those staff members and students whose work necessitates the operation of any irradiating apparatus (X-ray units), or the handling of sealed and/or unsealed radioactive sources. Students designated as radiation workers shall be under the direct supervision of a staff member.

Radiation workers shall:

  • Take care for their own and others safety
  • Cooperate with the University on radiation safety, follow all safety procedures, follow directions of the RSO and/or LSO
  • Be and remain informed of the radiation hazards associated with their work
  • Complete radiation safety training / refresher training
  • Be properly and adequately instructed in the use of each necessary safeguard and procedure
  • Work in a way to minimise radiation exposure to themselves, others and the environment
  • Take every precaution to avoid unnecessary exposure to radiation, and ensure that radiation doses are kept as low as reasonably achievable
  • Wear an appropriate personal monitoring device issued by the school at any time when the radiation worker is likely to be exposed to radiation, unless specifically exempted by Human Resources. The device is to be returned for assessment at the end of the prescribed period
  • Report immediately to the School RSO and the Health and Safety representative, any injury, accident, incident, hazard or near miss, known or suspected unsafe practice
  • Human Resources strongly advise discussion with supervisor and RSO if pregnancy is being considered or pregnancy is confirmed. Private discussion may also be undertaken with School Senior Advisor, Health & Safety
  • Work in such a way as to minimise the production of radioactive waste, ensure radioactive waste from their experiment is safely contained, packaged, labelled and disposed of
  • Follow directions of the RSO and/or LSO

Permits / licences / registration required

Licences

(a) The University is required to be licensed under the Radiation Act 2005 (Vic).

The RMIT license is for a period of 3 years and coordinated by Human Resources.

The RMIT license lists:

(i) Ionizing radiation apparatus, (ii) non-ionizing radiation apparatus, (iii)sealed sources and sealed source apparatus

These are the only sources that have been notified to Human Resources and consequently notified to DHS as being in RMIT possession. Whilst Management Licences may have as many as eight Schedules, RMIT Licence only includes Schedules that are relevant to the University Radiation practice.

(b) Individuals whose work involves irradiating a human subject (e.g. X-ray) must be licensed. This is called an operator license, it is available through DHS, and is to be paid for by the school concerned. Applications for these should be submitted by the school concerned. Human Resources is able to assist.

(c) Radiation workers who legitimately use radiation in the course of teaching or research at RMIT are generally covered by the University's license (as described above).

The exception is where the work involves the irradiation of human subjects (as described in (b) above), or where the work is performed on behalf of, or by a person or organisation outside RMIT. If there is any doubt as to the status of the radiation worker, Human Resources is to be contacted for clarification.

Registrations

(a) Sealed source apparatus and sealed radioactive sources of activity greater than the amounts exempted by DHS, and each irradiating apparatus owned and used by schools, must be registered under the Radiation Act 2005.

(b) The registration of each apparatus and sealed source shall be coordinated by Human Resources.

(c) A copy of the Department of Human Services registration form (for sealed sources and irradiating apparatus) shall be forwarded Human Resources after the form has been signed by the School RSO.

(d) Costs of these registrations are to be met by the school involved.

Risk assessment

  • A Risk Assessment must be completed for all proposed projects, where a project changes significantly, or annually for ongoing projects.
  • Risk Controls must be implemented which ensure risks identified in the risk assessment are controlled.
  • Results of the Risk Assessment should feed into other radiation safety activities e.g. training, workplace monitoring, waste management.

Specific training requirements

  • All staff and students working with radiation must complete general radiation safety training and a safety induction of the area they will be working in.
  • The RSO and LSO should receive adequate training, as well as being allowed adequate time and resources to do their job effectively.
  • Radiation Safety Officers and other relevant staff may complete advanced radiation safety training through an external provider.
  • Training courses should cover as a minimum: (NB: Training records must be kept by the school.)
    • Radiation hazards and how to avoid them
    • Safe working practices
    • Any device that may be necessary for safety
    • How to minimise radiation dose
    • Emergency procedures
    • Local safety procedures
    • University radiation procedures

Monitoring – workplace / personnel

Personal monitoring

  • All designated radiation workers shall wear an appropriate personal radiation monitoring device if there is potential for them to receive an occupational dose of radiation in excess of 1 mSv in a 12 month period.
  • The RSO shall ensure that personal monitoring devices are issued by the school to all designated radiation workers, collected and assessed immediately after the period of use.
  • All recorded dose equivalents shall be sent regularly by the RSO to Human Resources who will maintain records, assess dose equivalents of personnel and take appropriate action.

Workplace monitoring

  • Periodic monitoring of the workplace should occur. Frequency and techniques should be determined from completion of the Risk Assessment. Assistance is available from Human Resources.
  • Each school / laboratory should maintain access to suitable equipment to enable this does occur. External assistance may be sought where required.
  • Types of monitoring includes:
    • Workplace – to identify work areas where appreciable dose rates exist
    • Surface contamination – regular monitoring to see if work surfaces have been contaminated
    • Airborne contamination – air monitoring may be employed where there is a risk of airborne contamination

Examples include:

Wipe tests of surfaces / Radiation survey of the laboratory / Air monitoring for areas subject to hazards from airborne contamination

Procedure

New activities / research notification and acquisition of new radioactive source

  • All new projects and variations to projects involving radiation must be notified to Human Resources and the appropriate form filled out.
  • Human Resources shall assess all new activities and changes to existing activities for compliance with; legislation, the University’s Radiation License, this procedure, adequate radiation safety and industry standards.
  • Sealed and unsealed radioactive sources shall only be purchased or otherwise acquired with prior approval in writing from Human Resources. In the latter case the source shall be examined by a specially authorised officer or licensed tester with the full co-operation of the school.
  • In the case of unsealed radioactive sources the activity shall not exceed the amounts specified In the Radiation / Laser Project Notification Form submitted in regard to the source and project
  • In the case of unsealed sources no material shall be acquired unless there is provision for its safe usage, storage, and disposal.

Please refer to Reference Links at end of procedure.

Laser

  • Each laser installation in the University shall comply with AS2211 Laser Safety
  • Complete - Radiation / Laser Project Notification Form

Note: No class 3 or class 4 laser shall be used until an examination of the laser and laboratory facilities has been performed by Human Resources.

Acquisition of Non-ionizing Sources

Any non-ionizing radiation sources (such as UV lamps or microwave sources) which are likely to pose a health hazard should be notified to Human Resources prior to use. If there is any doubt regarding power levels or safety, Human Resources, RSO, LSO and the area HSR, as appropriate, should be contacted to arrange an examination of the unit.

Trial run of new activities

When conducting activities for the first time, a trial run should be conducted using a mock source and ensuring all relevant guidelines are utilised.

Research Involving Exposure of Humans to Ionizing Radiation

  • All research involving the exposure of humans to ionizing radiation must be approved by the University’s Ethics Committee.
  • Research involving human volunteers must only be carried out in accordance with ARPANSA – Code of Practice - Exposure of Humans to Ionizing Radiation for Research Purposes – No 8 – May 2005.

Administration of radiation to a person must only be done under the supervision of a licensed operator in the field of medical radiation.

Emergency procedures

Each school and/or laboratory must prepare local emergency procedures to cover all foreseeable emergencies that may occur from the use of radiation.

Safe work instruction

Each school and laboratory/s shall prepare Safe Work Instruction/s which are specific to the workplace and the work conducted in the area. All staff and students working in the area are to be familiar with these procedures and SWIs.

Incident reporting

All injuries, incidents, hazards and near misses resulting from the use of radiation must be reported to Human Resources immediately as well as an incident report being filled in.

Human Resources will conduct a full investigation and fill out Incident Report/s

Testing of radiation sources

Testing of radiation sources (including X-ray machines) by a person registered to carry out this work is required by DHS. The purpose of this is to certify their safe operation.

  • Radiographic X-ray equipment every 2 years
  • Fluoroscopic X-ray equipment every 2 years

Storage

  • Security:Storage of radiation sources including radioactive waste must at a minimum, achieve physical security measures capable of preventing unauthorised access to the source by human force. This may involve locked doors, safes, cupboards, swipe card access etc.
  • DG Segregation Chart: No incompatible materials shall be stored with radioactive materials.

(a) The storage area must be locked at all times when not in attendance.

(b) The storage area must be physically separated from the normal day to day operations of the laboratory.

(c) All entrances to the area should be appropriately labeled, in particular restricting access to authorised personnel only.

(d) The area must be kept in such a way as to ensure accidental contamination of persons is extremely unlikely.

Restricted access

(a) Access to areas in which irradiating apparatus, unsealed radioactive substances or sealed radioactive sources of activity greater than the exempt amount are stored or used, shall only be allowed for persons that have legitimate reason for accessing the area.

All areas in which irradiating apparatus are in use shall be designated as restricted access, for the period during which such apparatus is energised. The location of all controlled areas shall appear on the University radiation inventory and the Department of Human Services licenses and registrations.

(b) The standard of facilities and conditions in a restricted access area shall conform as a minimum, to the requirements of the Regulations and any prescribed standards.

(c) Persons who are not designated radiation workers shall not work, nor remain for any length of time, in restricted access areas.

(d) All restricted access areas shall be supervised by a responsible radiation worker, or RSO.

(e) The RSO must inform Human Resources of any changes to facilities conditions or the nature of the operations conducted within any restricted access area and of any alteration to the radiation inventory of that area – as this may affect RMIT Licence reporting requirements.

Signage and labelling

(a) In restricted access areas, all entrances to rooms where radiation is employed must be signed with the radiation warning symbol, and located in places in which they will readily be seen.

(b) Each storage area or work area employing radioactive substances shall be posted with appropriate radiation hazard labels.

(c) Each container of radioactive substance shall bear a clearly visible label containing the radiation symbol, identifying the radioactive substance, its activity and date of measurement.

(d) Each irradiating apparatus shall have a radiation hazard label with appropriate wording posted on it.

(e) Entrances to rooms where lasers are used must be signed with the laser symbol, laser class and wavelength.

(f) Lasers must be labeled with the laser symbol; accessible parts of the laser must also be labeled.

Transport of radioactive materials (including waste)

Transportation of any radioactive material from the restricted access area where that material is usually stored or used, shall be approved by the RSO prior to transportation. All statutory requirements for such transport shall be met by the school.

Transport within a building

To ensure that the risk of an ionizing radiation incident is minimised, the following practice should be followed:

  • Conduct risk assessment for transportation
  • Ensure that packaging is robust and includes secondary containment to prevent spills.
  • Laboratory waste disposal management strategy procedure States - Spill kits and appropriately trained staff must accompany wastes
  • Take the shortest and/or least populated route to your destination.
  • Do not transport ionizing radiation sources within buildings during peak traffic times, e.g. lecture start and end times.
  • Ensure that a second radiation worker accompanies you during the transport. In case of accident one person can stay at the scene and the other person seek assistance.
  • Minimise your exposure during the transport, e.g. use a trolley to maximise the distance between the ionizing radiation source and your body. (Note: if a trolley is used the source must be secured so that it cannot readily fall off the trolley).
  • Never leave an ionizing radiation source unattended.

Transport between buildings

  • The precautions detailed above for transport within a building also apply to transport of ionizing radiation between buildings. In addition you need to consider that there are likely to be more members of the public around.
  • Do not transport ionizing radiation sources between buildings during peak traffic times, e.g. lecture start and end times.

Note: transport of ionizing radiation sources by road whilst on campuses is not permitted unless it is carried out in accordance with the requirements detailed below for transport off campus. This is due to the fact that the majority of roads on campus are considered public roads.

Transport off campus

Transport of ionizing radiation off campus must be carried out in accordance with the ARPANSA - Code of Practice for the Safe Transport of Radioactive Material (2008) and in consultation with Human Resources.

All off-campus transport of radioactive materials must be via a contractor licensed to do so.

Disposal of radioactive sources

Sealed and unsealed sources

  • The RSO shall notify Human Resources when radioactive source(s) are no longer needed and require disposal.
  • Human Resources will inform DHS
    • Request Disposal Form
    • arrange for the University Radiation License to be amended
  • The RSO shall ensure that sources are adequately and safely packaged. Advice on the correct packaging can be obtained from Human Resources.
  • Human Resources can assist schools with the disposal of radioactive sources.

The following is suggested:

1. In the event of sources purchased from a licensed supplier the source is to be returned to the supplier where possible.

2. In the event of sources being lent, sold or given to a person or organisation other than within RMIT, Human Resources shall ensure that the person or organisation is licensed to accept the source.

3. In the event of difficulty in tracing the original supplier or identifying the source, the Department of Human Services should be contacted to arrange for removal and subsequent disposal.

Irradiating apparatus

Irradiating apparatus may be disposed of into landfill or sent for recycling if the apparatus has been permanently disabled by cutting the high voltage wires to the tube.

Any other hazards (e.g. cooling oil) must be addressed. (Refer: http://hsis.ascc.gov.au/News.aspx)

Waste management

  • Work shall be conducted in such a way as to minimise the amount of radioactive waste produced. Assessment of waste minimisation and management shall be conducted in the project planning phase.
  • The RSO shall be responsible for ensuring the safe handling and disposal of radioactive waste from their laboratory.
  • It is the responsibility of each radiation worker to ensure that the radioactive waste from their experiment is safely contained, packaged, labeled, stored and disposed of.
  • Disposal must not be made via any laboratory or other sink without obtaining written approval from Human Resources.
  • All radioactive wastes should be disposed of at the earliest opportunity. Short lived waste may be stored to be allowed to decay.
  • Radioactive wastes (i.e. solid, solvent or aqueous) shall be disposed of through a licensed contractor, or following contact with Human Resources.
  • No radioactive waste shall be removed from RMIT University until the waste has been monitored and approved by Human Resources.
  • Wastes must be transported only via goods elevator – to ensure no public access to elevator > lock off (where ever possible transport After Hours).
  • All containers must be packed to minimise the risk of breakage or rupture.
  • Spill kits and appropriately trained staff must accompany wastes.
  • Under no circumstances should radioactive waste be left unattended anywhere outside the laboratory or waste storage area.

Radioactive waste can belong to any of the following categories:

(a) Solid, dry waste

This category includes contaminated paper, tissues, glassware, syringes, pipettes, and containers. The container should be clearly labeled with the radioisotope, measured / estimated activity, date of activity estimate / measurement and name of the researcher. This label should be taped on securely to the outside of the package. Sharp objects must be packed to avoid puncture of the bag under all handling conditions. Human Resources should be contacted to advise on the appropriate method of disposal.

(b) Low level non-aqueous waste

This category includes solvents, volatile liquids and insoluble radioactive materials. These should be sealed in secure non-corrosive containers and clearly labeled with the radioisotope, estimated activity, date of activity estimate / measurement and name of the researcher.

Note: that the labeling of all radioactive solvent wastes must comply with the University's procedures for labeling of non-radioactive solvent wastes. Human Resources should be contacted to advise on the appropriate method of disposal.

(c) Aqueous waste

This is material which is readily soluble and dispersible in water. The waste should be sealed in secure corrosion resistant containers and clearly labeled with the radioisotope, estimated activity, date of activity estimate / measurement and name of the researcher. Human Resources should be contacted to advise on the appropriate method of disposal.

Non ionizing radiation

Each laboratory or area using non-ionizing sources such as ultra-violet lamps or microwave sources should comply with The Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) publishes Codes of Practice or Standards.

Pregnancy

  • Human Resources strongly advise discussion with supervisor and RSO if pregnancy is being considered or pregnancy is confirmed. Private discussion may also be undertaken with the School Senior Advisor, Health and Safety, Human Resources should also be notified as soon as possible.
  • When an employee declares that she is pregnant, the embryo or foetus should be afforded the same level of protection as required for members of the public (i.e. effective dose of 1mSv). Active measures are required where doses may exceed 1 mSv for the remainder of the pregnancy.
  • Human Resources shall be responsible for the evaluation of the dose report of the radiation worker to ensure that the relevant dose-equivalent limits are not exceeded.

Radiation workers who fall pregnant may ask to be excluded from working with ionizing radiation.

Medical examinations and health surveillance procedures

Except in the case of accidental exposure to high doses, no specific radiation related medical examinations are normally required for persons who are occupationally exposed to ionizing radiation, as there are no diagnostic tests which yield information relevant to exposure at low doses. Where required, health surveillance should follow general occupational medical practice for determining fitness for work.

Personal radiation monitoring:

As per Schedule 2, Radiation Regulations 2007 (Vic) – Occupational Exposure 20 millisievert per year averaged over a 5 year period – pregnancy 1 millisievert over the duration of the pregnancy

Non compliance

Non compliance with this procedure and radiation SWIs may result in disciplinary procedures being implemented against the non compliant person.

Records

Record Type

Retention time

Responsibility

Incident Reports

Indefinitely

Human Resources

Notifiable Incidents reported to WorkSafe

5 years

Human Resources

Incidents reported to DHS

5 years

Human Resources

Unsealed radioactive source license

Indefinitely

Human Resources

Radiation Equipment Licenses

2 years after disposal of the radioactive source

Human Resources

Inventory / Location of Radioactive Sources

2 years

Human Resources

Health surveillance reports

Indefinitely

Human Resources

Notification of Pregnant Radiation Worker

Indefinitely

Human Resources

Personal monitoring records

Indefinitely

Human Resources

Workplace monitoring records – Ionizing radiation

Indefinitely

Human Resources

Workplace monitoring records – non ionizing radiation

5 years

Human Resources

First Aid Reports

Indefinitely

Human Resources

Staff Training

Indefinitely

Head of School / Manager/ Human Resources

Purchase, transport, transfer, disposal, loss of a radioactive source

2 years (AS2243.4-1998)

Schools / Human Resources/work units

Operator Registrations

2 years

School/work units

Safe work instructions

While applicable

School

Purchase of ionizing radiation sources

2 years after disposal of the source

School

Audits / Inspections / Safety Checks

5 years

Head of School

Maintenance / Service Records

For the life of the equipment

Head of School

Calibration records

For the life of the equipment

Head of School

Risk Assessment

Until Review or at least 5 years

Head of School

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