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Radiation Protection Program
2012
Environmental Health and Safety Department
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Environmental Health and Safety Department

TABLE OF CONTENTS

  • PREFACE
    1. INTRODUCTION
    • 1.1. Purpose
    • 1.2. ALARA Philosophy and Policy
    1. EMERGENCY PROCEDURES
    • 2.1. Emergency Contact Information
    • 2.2. Radiation Emergency Procedures
    1. USER DEFINITIONS AND RESPONSIBILITIES
    • 3.1. Mines Management
    • 3.2. Radiation Safety Officer
    • 3.3. Authorized Users.......................................................................................................
    • 3.4. Independent Supervised Users.................................................................................
    • 3.5. Directly Supervised Users
    • 3.6. Ancillary Personnel
    • 3.7. Radiation Producing Equipment Supervisor
    • 3.8. Radiation Producing Equipment Operators
    1. RADIATION SAFETY TRAINING
    • 4.1. Rules and Regulations
    • 4.2. Training Module Content
    • 4.3. Training Procedure
    1. RADIATION USE AUTHORIZATION
    • 5.1. Licensing
    • 5.2. Information Required for Use of Licensed Materials.................................................
    • 5.3. License Amendment Proposals
    1. ACQUISITION AND USE OF RADIOACTIVE MATERIALS
    • 6.1. Purchasing
    • 6.2. Receiving
    • 6.3. Shipping and Transfer
    • 6.4. Storage and Security
    1. GENERAL RADIOISOTOPE LABORATORY SAFETY PROCEDURES
    • 7.1. Laboratory Safety Procedures
    • 7.2. Laboratory Record Keeping
    1. CONTROL AND MONITORING OF RADIATION EXPOSURES
    • 8.1. Radioactive Materials and X-rays
    • 8.2. Personnel Monitoring
    • 8.3. Occupational Dose Limits
    • 8.4. Public Dose Limits.....................................................................................................
    • 8.5. Bioassays
    1. LABORATORY SAFETY EVALUATIONS AND SURVEYS
    • 9.1. Sealed Source Leak Tests
    • 9.2. Contamination Surveys
    • 9.3. Airborne Activity
    1. RADIOACTIVE WASTE MANAGEMENT
    • 10.1. Waste Collection and Packaging
    • 10.2. Labeling of Radioactive Wastes................................................................................
    1. RADIATION SAFETY PROGRAM MANAGEMENT
    • 11.1. Recordkeeping and Forms........................................................................................
    • 11.2. Portable Radiation Survey Instrument Calibration
    • 11.3. Annual ALARA Review
    1. PREGNANT WORKERS’ DECLARATION AND RISKS
    • 12.1. Rules and Procedures
    • 12.2. Potential Health Risks
    • 12.3. Declaration Procedures
    1. RADIATION PRODUCING EQUIPMENT
    • 13.1. Rules and Regulations
    • 13.2. Operating Requirements
    • 13.3. Survey/Exposure Monitoring

PREFACE

This document is designed to provide practical safety and regulatory guidance to

ionizing radiation users at the Colorado School of Mines (Mines). Details on the

regulations and specific radiation guidance can be found in the Mines

Environmental Health and Safety (EHS) Department/Radiation Safety Office.

The Mines EHS/Radiation Safety Office has a set of operating instructions

entitled, “Health Physics Instructions” (HPIs). These provide guidance to Mines

radiation safety personnel. As these may have impact on a radiation user’s

program and may provide detail on safety procedures, users are encouraged to

review these instructions.

2. EMERGENCY PROCEDURES

2.1. Emergency Contact Information

EHS Department (24 hour) 303-273- EHS Director (cell) 303-807- Radiation Safety Officer (cell) 303-324-

CSM Public Safety 911 or 303-273-

Golden Police/Fire Department 911 or 303-384-

2.2. Radiation Emergency Procedures

Immediately notify EHS in the event of a Radiation Emergency.

Call 911 in the event of fire, explosion, injury, or other life threatening conditions.

The School maintains an Emergency Response Team which manages incidents involving radioactive materials. Specific emergency response procedures are described in three internal documents. Copies of these documents are available in the EHS Departmental Office in Chauvenet Hall. These documents are:

a) Hazardous Materials Response Plan b) Emergency Procedures and Contingency Plan c) Preparedness and Prevention Plan

2.2.1. Notifications

In the event of an emergency involving radiation, EHS should be notified as soon as possible. If the emergency is life threatening, Mines Public Safety (911) should be contacted. Be sure to indicate that radiation is involved. Have the following information available for emergency personnel:

  1. Your name and the name of the Authorized User in charge of the laboratory.
  2. Type of radiation incident (e.g., spill, X-ray malfunction, lost sealed source, etc.).
  3. The location of the incident (e.g., building, room number, location of spill or machine in the laboratory).
  4. A phone number where you can be reached, as well as the location where you will meet emergency personnel.
  5. The radioisotope (or energy if an X-ray machine).
  6. The estimated activity involved.
  7. The volume of material involved.
  8. The chemical form of the compound.
2.2.2. Procedures for Spills – Major
There are large spills and small spills. Large spills involve alpha emitters of
>1 μCi and beta/gamma emitters of > 100 μCi. For large spills, users should
follow this simple guide.
If a medical emergency is associated with the radiological emergency, GET MEDICAL
HELP IMMEDIATELY. Radiation emergencies are rarely life-threatening, and the
medical emergency always takes precedence.
Stage Action By
STOP Assess the situation. Any involved person
WARN Let everyone in the vicinity know about the
emergency.
Be emphatic.
Any involved person
ISOLATE AND
CONTAIN
If applicable, prevent spread of material and
contain the spill, e.g. use absorbent material.
Limit movements of potentially contaminated
people. Use protective personal equipment as
appropriate such as gloves.
Any involved person
MINIMIZE
EXPSOURE
This may be accomplished by methods as
simple as moving a sufficient distance from
the RAM or by placing a shield of sufficient
material (ex. door), between you and the
source to attenuate the radiation.
Any involved person
INFORM Notify immediate supervisor
Notify EHS (Phone ext. - 3316)
CSM Police, at 911, (indicate it is a radiation
emergency)
Any involved person
EHS and support will perform the following
ASSESS Investigation and assessment Radiation Safety
DECISION Declare emergency and determine involved
area
Emergency Director,
RSO, or designate.
RESPONSE 1. Activate and assure appropriate
responses
2. Rad assessment, supply, protection,
and corrective action
3. Notification, corrective actions
4. Evacuations and communications
1. RSO
2. HP
3. Line operations
4. Staff support
RECOVERY 1. Declare termination
2. Plan for future
1. RSO
2. All units

evident, start decontamination procedures immediately by washing with detergent and large volumes of water. Contact EHS for any case of skin contamination.

  1. Evaluate the Wipe Test – Determine if the clean up effort was successful. Are there any spots with removable activity? If so, contact EHS for advice/assistance to complete the decontamination. If the wipes are not significantly higher than background, perform a final surface survey with an appropriate survey instrument to determine the level of fixed radioactivity. Contact EHS in any case where there is fixed activity.

3. USER DEFINITIONS AND RESPONSIBILITIES

3.1. Mines Management

Mines management includes the School’s President, the Director of the Environmental Health and Safety (EHS) department, and the supervisors of Authorized Users such as Department Heads. Management is responsible to

  1. Support the ALARA policy and the Radiation Safety Program
  2. Be aware of ionizing radiation uses on campus
  3. Assure that ionizing radiation is being safely used

3.2. Radiation Safety Officer

The Radiation Safety Officer (RSO) is a member of the Environmental Health and Safety (EHS) department and is the individual named on the School’s radioactive materials license. The RSO supervises the use of radiation on campus and reports to the Director of the EHS department. The RSO is responsible to:

  1. Be the lead in assuring adherence to ALARA
  2. Assure adherence to all radiation regulations issued or subscribed to by the School.
  3. Implement the organization, administration and management of the School’s Radiation Safety Program.
  4. Interpret regulations which govern the uses of ionizing radiation and disseminate information on radiation safety.
  5. Interact with regulatory agencies and assure that Mines is properly licensed for ionizing radiation uses including licenses and registrations.
  6. Approve new authorized users and radiation workers. Maintain an accurate database of approved users and their training.
  7. Review and approve new proposals for radiation use and assure that regulatory requirements are met.
  8. Coordinate the dosimetry service, maintain personnel exposure records, and give timely notice of over-exposures to the individual, the individual’s supervisor and regulatory agencies when appropriate.
  9. Review and approve procurement requests for radioactive materials and radiation producing machines to assure compliance with limitations for possession and use.
  10. Maintain an accurate inventory of radioactive materials and radiation producing equipment. Maintain records of radioactive materials and radiation producing equipment transfer, storage or disposal
  11. Instruct radiation users and Mines employees on radiation safety.
  12. Manage the radioactive waste disposal program and maintain disposal records.
  13. Conduct periodic radiation safety surveys of radioactive material and radiation producing equipment uses and locations.
  14. Perform required sealed source leak tests and report abnormal results
  15. Assure the appropriate calibration of portable monitoring and survey equipment.
  16. Report to appropriate authorities and any reportable radiation incident or event which may have resulted in injury, contamination or damage to property.
  17. Delegate duties and responsibilities to qualified personnel.
  1. Survey hands, shoes, body and clothing for radioactivity and decontaminate before leaving the lab (for radioactive material users working with unsealed sources).
  2. Check work areas at the end of each work session for contamination and decontaminate as necessary (for users working with unsealed sources). Maintain survey records as required.
  3. If required, wear personal dosimetry and submit bioassay samples.
  4. Use recommended or required personal protective equipment and equipment such as protective clothing, eye shields, gloves, shielding, glove boxes, respiratory protection, etc.
  5. Maintain an accurate inventory of radioactive materials.
  6. Maintain security of radionuclides both while in use and in storage.
  7. Properly dispose radioactive wastes and maintain disposal records.
  8. Report immediately to the AU and the RSO any accident involving radioactive materials or radiation producing equipment.
  9. Assure dose rates in work area are ALARA and assure ancillary personnel do not get excessive exposures (> 50 mrem/yr or 2 mrem/hr).

3.5. Directly Supervised Users

Directly Supervised Users (DSU) are persons who have not completed a radiation safety training course. Directly Supervised Users may not handle radioactive materials except under direct supervision of the Authorized User or RSO. It should be a relative rare situation for a person to be designated as a DSU, but it is sometimes necessary for short term visiting researchers or other situations. The AU is wholly responsible for the DSU’s safety. The AU or RSO must provide awareness training to the DSU and assure that the DSU does not exceed 100 mrem in a year.

3.6. Ancillary Personnel

Ancillary Personnel (ANP) are individuals whose duties include working in the presence of any licensed radiation source or require unaccompanied access to controlled radiation use areas. Ancillary Users are not permitted any direct involvement with the use of any radiation source. The AU, or designee, must assure that the ancillary person receive awareness training. The RSO routinely gives awareness training to some ancillary personnel such as facility personnel and custodians. This may be applied to the ancillary personnel training, but the AU or ISU is responsible to point out areas where ancillary personnel need to take caution or are not allowed to enter.

3.7. Radiation Producing Equipment Supervisor

Radiation producing equipment (RPE) includes X-ray machines and particle accelerators. A qualified faculty member shall be responsible for the use and maintenance of each item of radiation producing equipment. The supervising faculty member is responsible to

  1. Provide safety training to staff members and students who are authorized to operate the equipment.
  2. Assure that only persons who are authorized and trained by the supervising faculty member are allowed to operate radiation producing equipment.
  3. Assure that the RPE is installed in a safe manner such that it assures safety for workers and those who may be near the equipment.
  4. Assure that safety mechanisms on the RPEs are functional and operating correctly.
  5. Assure that the RPE is registered with the State of Colorado if required.
  1. Assure that regular inspections of the RPE are performed.
  2. Report to RSO any modifications, repairs, replacements and maintenance on the RPEs. Report to RSO any status changes including transfer, lost/stolen, or out of services.
  3. Assure proper dosimetry is used.

3.8. Radiation Producing Equipment Operators

Operators of RPE are responsible to

  1. Understand operating procedures and safety precautions.
  2. Assure that operations are conducted safely.
  3. Check that safety devices are working properly.
  4. If required, wear personal dosimetry.
Module 2 - “Physics Review”

This module provides basic radiation physics and health physics information.

Module 3 – “Radiation Interactions with Matter”

This module provides basic information on how radiation interacts with matter, appropriate shielding and radiation detection devices.

Module 4 – “Biological Effects of Radiation Exposure”

This module provides information on the effects of external radiation exposure.

Module 5 – “External and Internal Radiation Dosimetry”

This module provides information on the effects of internal radiation exposure.

Module 6 – “Safe Lab Practices”

The objectives of this module are lab specific to:

  1. Review ALARA principles.
  2. Review lab safety procedures and emergency procedures.
  3. Review routes of entry and personal protective equipment.
  4. Discuss in-lab record keeping and documentation.
  5. Review waste collection practices.
  6. Demonstrate relevant procedures in the laboratory setting.
Awareness Training

The objectives of this training are to inform those not using radiation in a lab about the radiation hazards in the lab. The training content includes

  1. Signage recognition.
  2. Location of radiation sources.
  3. What to do in an emergency.

4.3. Training Procedure

4.3.1. Authorized User (AU) initiates “CSM Radiation User Information” form. AU determines user’s category and sends form to RSO. Alternately, the AU can send the new user to the RSO for direct evaluation.

4.3.2. RSO reviews form and analyzes for dosimetry and training needs. RSO schedules training and initiates data entry.

4.3.3. Users receive training in accordance with their classification and needs.

Module 1: All new users of licensed radioactive materials (not including general-licensed materials) are required to attend Module 1 training. This module is only required to be attended once. Module 1 meets the requirements of the State of Colorado 6 CCR 1007- 1.10.3 “Instructions to Workers”.

Module 2: All prospective users of radioactive sources who require training concerning the fundamentals of nuclear physics must take Module 2.

Module 3: All prospective users of radioactive sources who require training concerning radiation interactions with matter must take Module 3.

Module 4: All prospective users of radioactive sources who require training concerning biological effects of radiation exposures must take Module 4.

Module 5: All prospective users of radioactive sources who require training concerning radiation dosimetry must take Module 5.

Module 6: All prospective users of radioactive sources who require training concerning safe laboratory practices must complete Module 6. The AU (RSO may assist) will tailor the training to the lab’s activities - specific to the research the individual will be conducting.

Awareness Training. The RSO, AU, designee or worker’s supervisor shall give a awareness training to ancillary personnel, visitors, maintenance workers or other person’s not using radiation who enter the lab. The RSO should provide awareness training to emergency response personnel.

4.3.4. RSO completes the “User Agreement and Authorization” form as applicable and updates the radiation safety training database.

and designated radiation work areas. The RSO will evaluate the submittal and determine if the locations are adequate. Authorized Users using sealed sources may be required to have leak tests performed in accordance with State regulations. The RSO can make this determination and coordinate periodic leak testing. Authorized Users using only sealed sources are not required to submit wipe test locations for their laboratory.

5.2.5. Security

Discuss security measure in place to prevent unauthorized access to radioactive sources and waste considering shared room accessibility and other related issues.

5.2.6. Postings

Sources of ionizing radiation and the areas where they are located are required to have radiation warnings signs. The RSO will advise you as to what signage is appropriate. The RSO follows the regulatory guidance as issued by the State of Colorado Radiation Control regulations.

Discuss postings for doors, work areas, storage locations and instruments. Doors are required to have emergency numbers posted on the outside. Work areas should be posted with the appropriate labeling. Instruments used to count samples (LSC, gamma counters, etc.) need to be adequately posted.

5.2.7. Procedures and Safety

Provide methods, procedures, rules, etc. that will ensure radiation safety during the project. Procedures should address safety precautions during specific steps of the process that may generate increased doses to individuals, possible airborne release, and procedures to reduce waste and new procedures that have been developed to address safety and/or waste production. Detailed procedures are not necessarily required and should be discussed with the RSO.

Demonstrate appropriate laboratory safety measures. This should include the use of lab coats, types of gloves, complete coverage of legs and feet, personnel monitoring, eating and drinking in the laboratory, applying cosmetics in the laboratory and other precautions where appropriate.

5.2.8. Dose Estimates

Clearly show the calculations for the expected internal doses for all users. Demonstrate that normal working time doses do not exceed occupational dose limits. Calculate worst-case dose scenarios and inform individuals working in the laboratory. The RSO can help you determine this information.

5.2.9. Waste Disposal Plan

Discuss the quantity of waste that will be generated including mixed and biohazardous waste. List methods used to minimize waste generation. Describe the waste containers that will be used.

5.2.10. Instrumentation and Surveys

List in detail the radiation safety equipment that will be used during the project. Indicate if it is borrowed or shared. The RSO will evaluate if it is appropriate for the type of radiation material being used. A liquid scintillation counter must be used for tritium detection. Include the frequency of wipe test that will be performed.

5.3. License Amendment Proposals

Any desired revisions to an authorization should be discussed with the RSO. If the RSO determines that the proposed revision does not involve any change from the initial safety evaluation, and is within the intent of the initial authorization, the revision may be approved by the RSO. If the proposed revision involves significant changes in sources or conditions of use from those specified initially, the proposal must be submitted to the CDPHE for authorization.

Upon request by qualified faculty members, the RSO will prepare requests for amendments to the School’s radioactive materials license. Amendments are needed whenever radioactive material is to be added or deleted from the license, authorized users are added or deleted, or the purpose, location or procedures for handling licensed radioactive materials are changed.

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