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Category Health and Safety
Type Code of Practice
Approved by Council, 23 September 2009
Date Code of Practice Took Effect 1 September 2009
Last Approved Revision
Sponsor Director of Human Resources
Responsible Officer Head, Health and Safety Compliance
Review Date 30 September 2014

Purpose

This Code of Practice describes how the University of Otago manages the use of ionising radiation to ensure the protection of staff, students, member of the public and patients.

Organisational Scope

The ionising radiation safety policy requirements apply to all work areas of the University of Otago where ionising radiation is in use. This includes exempt and non-exempt sources as defined by the Radiation Protection Act (1965) and regulations.

Policy Content

1. Introduction

This document describes how the University of Otago manages the use of ionising radiation to ensure the protection of staff, students, member of the public and patients.

All applications of ionising radiation and radioactive materials, including purchase, use, storage and disposal, by university staff and/or students, or on Otago University premises must meet the requirements of this plan.

Local Radiation Safety Plans (RSP)’s must be prepared at dept/unit/laboratory level wherever ionising radiation is used within Otago University, and these plans must follow the guidance given here.

This plan has been approved by the HSRC, by the University Risk Management and Statutory Compliance Committee and the Vice Chancellor.

This plan will be reviewed annually by the HSRC while minor changes may be incorporated at any time on the written authority of the University Radiation Safety Advisor (RSA).

2. Why is Radiation Used at Otago University?

Ionising Radiation is used when there is a net benefit to society from teaching or research, or to the clinical management of a patient, and where it is the most appropriate methodology. Individual activities are justified in local Radiation Safety Plans.

3. The persons who must read this document

This plan, and the appropriate local plan(s) must be read by everybody involved in the use of ionising radiation at Otago University, including those involved at management, supervisor and work levels. This includes students engaged in research work, but undergraduates doing set experiments must be adequately instructed and directly supervised in their laboratory.

4. How does Otago University use ionising radiation?

Otago University uses ionising radiation for teaching, research and for the clinical management of patients (in Health Sciences).

Throughout the institution all uses of ionising radiation are within the scope of this plan and meet the requirements of the Radiation Protection Act (1965) and Regulations (1982). This applies even if Otago University is not the owner of the radiation source.

All activities involving ionising radiation must be conducted in accordance with a local Radiation Safety Plan. These plans should follow a common format. The University Health & Safety Office will keep copies of local Radiation Safety Plans, which will be approved by the RSA and reviewed annually.

Where required by the Act, the use will be under the control of an individual, or individuals, licensed under the Act, who will work within the local RSP, where appropriate a Code of Safe Practice issued by the National Radiation Laboratory (NRL) and other conditions specified on the licence.

The Otago University Health & Safety Office will maintain a register of all those controlling the use of ionising radiation within Otago University and, where a licence is held, a copy of the licence and a copy of the inventory of controlled radiation sources.

5. Radiation Dose Constraints and limits.

All activities involving ionising radiation at Otago University shall be organised and resourced (in facilities, equipment and training) in such a way as to keep the radiation doses to any individual as low as reasonably achievable, economic and social factors taken into account.

Individual doses to workers and members of the public are limited to those specified by National Radiation Laboratory (NRL) at any time.
When doses might exceed 30% of any limit, a scheme of monitoring, agreed by the RSA must be in place. When such monitoring takes place, copies of staff radiation doses must be forwarded to the Otago University Health & Safety Office.

6. Hazard Assessment

All uses of ionising radiation shall include in the Local Radiation Safety Plan an assessment of possible hazards, including those which might arise from accidents or equipment malfunctions. Possible radiation doses may be calculated to help with contingency resources and risk management.

When research involves exposing humans to ionising radiation the ethics committee will require a dose and risk assessment. The licensee and the RSA will jointly prepare this assessment.

7. Radiation Safety Advisor

The University will appoint a Medical or Health Physics expert with appropriate expertise in managing radiation hazards to provide professional oversight of the University RSP and local RSP’s.

(a) Duties of the University Radiation Safety Advisor

Advise the University, through the Hazardous Substances and Radiation Advisory Group, on matters relating to radiation safety including:

(i) Assist licensees in the preparation of local Radiation Safety Plans; including safe working procedures with respect to radiation protection for use in a routine operation or in an emergency or accidental exposure;

(ii) Radiation monitoring programmes;

(iii) Condition of and need for radiation monitoring and protective equipment;

(iv) Action to be taken to reduce the radiation exposure of employees or members of the public to a level that is both below the radiation protection limits prescribed in the Radiation Protection Act 1965, the Radiation Protection Regulations 1982 and in the Codes of Safe Practice issued by the National Radiation Laboratory, and as low as reasonably achievable, social and economic factors being taken into account;

(v) Action to be taken in the event of an emergency or accidental exposure;

(vi) Collaborate with licensees and the NRL in determining the boundaries of responsibilities between licensees, and the responsibilities of Principal Licensees.

(vii) Investigate, as appropriate, sources of radiation exposure, the radiation protection equipment and working procedures and recommend any change that would reduce the exposure of employees or members of the public to a level that is both below the radiation protection limits and as low as reasonably achievable, social and economic factors being taken into account

(viii) Investigate any defect in an area or item of equipment that may increase the exposure of a person to radiation and recommend how to correct that defect;

(ix) Assess the accumulated effective dose and committed effective dose of any employee or class of employees. (The Committed Effective Dose, E(τ) is the time integral of the effective dose rate where is the integration time (in years) following an intake to the body of a radioactive material. is usually taken to be 50 years for adults and from intake to age 70 years for children unless otherwise specified.);

(x) Support licensees in the initial and continued instruction of employees in radiation hazards, safe working procedures to ensure radiation protection, the proper use of radiation monitoring and protective equipment, and measures to limit radiation exposure;

(xi) Support licensees to ensure that appropriate radiation protection monitoring surveys are carried out as required;

(xii) Assist licensees to set up or cause to be implemented personal monitoring systems for the determination of effective doses for any employee or class of employees, as required;

(xiii) Advise licensees regarding radiation monitoring and radiation protection equipment and its calibration and maintenance;

(xiv) To advise licensees about radiation signs and their location;

(xv) To advise licensees, where required, about the transport of radioactive materials;

(xvi) To oversee the maintenance of radiation hazards database by the Otago University Safety Officer. This database to include:

  • All areas in Otago University, where sources of ionising radiation are used, and those supervising the use of radiation.
  • Local Radiation Safety Plans
  • Licensees and the conditions on the licences.
  • Controlled radiation sources owned by OU, or used, or stored, on OU premises.

(xvii) Maintain detailed records on all the above matters.

(b) Radiation Safety Officer - Typical Duties

The Radiation Protection Regulations 1982 permit a licensee to appoint a Radiation Safety Officer in respect of any radioactive material or irradiating apparatus or in respect of any particular area. The exact duties, and extent of responsibilities, of the RSO will be documented in the local RSP, but would typically include some, or all, of the following:

(i) Advise the licensee who possesses or controls the source, on matters relating to radiation safety including –

  • radiation monitoring programmes;
  • condition of and need for radiation monitoring and protective equipment;
  • action to be taken to reduce the radiation exposure of employees or members of the public to a level that is both below the radiation protection limits and as low as reasonably achievable, social and economic factors being taken into account; and
  • action to be taken in the event of an emergency or accidental exposure;

(ii) Prepare safe working procedures with respect to radiation protection for use in a routine operation or in an emergency or accidental exposure;

(iii) Be responsible for the initial and continued instruction of employees in radiation hazards, safe working procedures to ensure radiation protection, the proper use of radiation monitoring and protective equipment, and measures to limit radiation exposure;

(iv) Ensure that appropriate radiation protection monitoring surveys are carried out as required;

(v) Set up or cause to be implemented personal monitoring systems for the determination of effective doses for any employee or class of employees, as required;

(vi) Maintain or cause to be maintained, sufficient radiation monitoring and radiation protection equipment and to ensure that that equipment is calibrated and in a ready and working condition;

(vii) Investigate any defect in an area or item of equipment that may increase the exposure of a person to radiation and recommend how to correct that defect;

(viii)Investigate sources of radiation exposure, the radiation protection equipment and working procedures and recommend any change that would reduce the exposure of employees or members of the public to a level that is both below the radiation protection limits and as low as reasonably achievable, social and economic factors being taken into account;

(ix) Observe whether the prescribed standards for the discharge of any radioactive waste are complied with before and during a discharge;

(x) Ensure that prescribed radiation signs are maintained in good condition and located in places in which they will be readily seen;

(xi) Monitor transport containers and ensure that they comply with the Regulations;

(xii) Maintain detailed records on all the above matters.

8. Responsibilities of Otago University and Licensee

(a) Otago University shall ensure that at all times a suitably licensed person is responsible for the safe care of all radioactive material or irradiating apparatus and shall provide adequate equipment and materials to enable the storage, use, transportation and disposal of the radioactive material or irradiating apparatus to be carried out safely.

(b) Every licensee shall be responsible for the safe care of any radioactive material or irradiating apparatus under his or her control.

(c) Otago University will clearly define licensee’s areas of responsibility, including the roles of Principal licensees.

(d) In the case where no suitably licensed person is available locally, responsibility may be temporarily transferred to the Otago University RSA. This will normally entail any radioactive material being placed in secure storage and irradiating apparatus being rendered inoperative.

(e) A licensee giving up their responsibilities must ensure that responsibility is passed to another suitably licenced person and these changes are notified to the Otago University Health and Safety Officer and to the NRL.

9. Every licensee shall:

(a) Ensure that all those who use the radioactive material or irradiating apparatus covered by their licence, follow the local RSP, the Otago University RSP, the Act, the Regulations and any relevant NRL Code of Safe Practice.

(b) Fully instruct every such person regarding the radiation hazards and related precautions.

(c) Make available to such person all the relevant documents (local RSP, Otago University RMP, Act, Regulations, Code of Safe Practice).

(d) Keep a record of all those persons currently trained and competent to work in their area.

(e) Keep a signed record that those persons have read and will comply with the local RMP and relevant NRL Codes.

(f) Ensure that the necessary resources to enable safe working practices and compliance are available.

(g) Prevent unauthorised persons from tampering with the radioactive materials or irradiating apparatus, and to keep them under control.

(h) Ensure that any equipment which exposes humans to ionising radiation is maintained according to the manufacturer’s requirements and is serviced at least annually.

(i) Ensure that any equipment which exposes humans to ionising radiation is subjected to a critical examination by a Medical Physicist licensed in radiology at least annually

(j) In the event of the loss, or release beyond the control of the licensee, of any radioactive material (other than proper disposal), steps must be taken to minimise the consequent hazard. The licensee should seek advice and assistance from the Otago University RSA, Otago University Health and Safety Office and, if judged appropriate, the NRL. If the possibility exists of anyone receiving a dose approaching the Member of the Public limit, then the NRL must be notified.

Contact for Further Information

If you have any queries regarding the content of this policy or need further clarification, contact Andrea McMillan on andrea.mcmillan@otago.ac.nz or (03) 479 7380.