RADIATION SAFETY MANUAL - Office of Risk Management · 2018-03-22 · UO- Office of Risk Management...

RADIATION SAFETY MANUAL

Office or Risk ManagementAssistant Directory Radiation Safety,Risk Management Specialist ‐ Radiation

[email protected]

safety, security

and

compliance

UO- Office of Risk Management RADIATION SAFTETY MANUAL

Table of Contents

RADIATION SAFETY PROGRM

TABLE OF CONTENTS

Chapter Section Sub-section

1 CORPORATE OVERSIGHT

1.1 RADIATION SAFETY PROGRAM 1.1.1 CNSC – Obligations of the Licensees and the Workers 1.1.2 Structure of Radiation Safety Program 1.1.3 Roles and Responsibilities

1.1.3.1 Radiation Safety Committee 1.1.3.2 Radiation Safety Officer 1.1.3.3 Risk Management Specialist - Radiation 1.1.3.4 Permit Holders 1.1.3.5 Users

1.1.4 Facilities and Equipment 1.1.5 Radiation Safety Training 1.1.6 Procedures

1.2 GETTING STARTED 1.2.1 Principle Investigators 1.2.2 Students (Users) 1.2.3 Internal Radioisotope Permits 1.2.4 TRAINING 1.2.5 CNSC License

2 OPERATIONAL PRACTICES 2.1 ALARA 2.2 EMERGENCY RESPONSE PROCEDURE

2.2.1 Spill Response Procedure 2.3 DOSIMETRY

2.3.1 Dosimeters 2.3.2 Dosimetry Service 2.3.3 Dose Records 2.3.6 Thyroid Monitoring 2.3.7 Pregnancy

2.4 INVENTORY 2.5 PURCHASING

2.5.1 Purchasing, Shipping and Receiving Factors 2.5.2 Purchasing Procedure 2.5.3 Shipping 2.5.4 Receiving 2.5.5 Transfers

2.6 TRANSPORTING

UO- Office of Risk Management RADIATION SAFTETY MANUAL

Table of Contents

2.7 MONITORING 2.7.1 Radiation Fields 2.7.2 Contamination Monitoring

2.7.2.1 Determining Regulatory Contamination Limit 2.7.3 Leak testing 2.7.4 Monitoring Packages

2.8 RADIATION DETECTION 2.8.1 Instrument Selection 2.8.2 Instruments Checks and Calibration 2.8.3 Relating to CNSC Criteria 2.8.4 Counting Efficiency 2.8.5 Direct Measurement using Portable Meter 2.8.6 Indirect Measurement using Wipes

2.9 WASTE MANAGEMENT 2.9.1 Procedures for Radioactive Waste Management 2.9.2 Radioactive Animal Carcasses Waste Disposal Procedures 2.9.3 Declassified Rad Waste for Hazardous Waste Pick-up

2.10 DECOMMISSIONING 2.11 RECORD MANAGEMENT 2.12 COMPLIANCE AND MONITORING ACTIVITIES 2.13 SECURITY

2.13.1 Theft 2.14 RADIOISOTOPE LABORATORIES

2.14.1 Classification 2.14.2 Physical Requirements 2.14.3 Design Requirements for Laboratories

2.15 SIGNAGE REQUIREMENTS 2.15.1 Signage Directive

2.16 SAFE WORK PRACTICES2.16.1 Safe Work Practices For Radioiodine (I-125 & I-131

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UO‐ Office of Risk Management RADIATION SAFTETY MANUAL

Corporate Oversight: Getting Started (1.2)

Approved by: ORM/lsp, jmm Current as of: 2018feb Page 1 of 2 Implementation Date: Oct. 2017

GETTING STARTED

1.2.1 PRINCIPLE INVESTIGATORS: In order to work with radioactivity at the University of Ottawa, first and foremost an Internal Radioisotope Permit is required. To apply for a permit complete the “permit application form”. Other critical requirements are laboratory space that meets radiation work requirements (refer to section 2.14 of this manual), detection equipment for contamination monitoring (refer section 2.8 of this manual), dosimetry (refer to section 2.3) and training. The latter two requirements, dosimetry and training, will be dealt with during the application process.

For permit application, see section 2.16 – forms.

1.2.2 STUDENTS (USERS): To work with radioactivity under a specific Principle Investigator’s Internal Radioisotope Permit, students must 1st complete the “new user registration form”. This form also documents the user’s in‐lab trainig and apon approval, the student may start working in the laboratory. It is expected that every user will attend the 3 hr in‐class Radiation Safety Training once it is offered.

For new user registration form, see section 2.16 – forms.

1.2.3 INTERNAL RADIOISOTOPE PERMIT: Information on Internal Radioisotope Permits covers all the major aspects of the radioactive usage in the laboratory. It identifies the type of radioactive material (sealed,unsealed…) and the radioisotope/s that can be used, the radioisotope activity limit of the that can be used in at any one time (Use Limit), the use and storage locations, and the authorized personnel who may work with the material. It is critical that all users comply with the Permit and the Permit Conditions (attached to the permit application), requirements outlined in the Radiation Safety Manual and procedures associated with the program. Non‐compliance, could result in the loss in the University of Ottawa’s Nuclear Substances and Radaition Devices License and thus have detrimental implications on the University’s teaching and research activities.

There are four main types of Internal Radioisotope Permits and they are: 1. Unsealed Radioactive Material2. Sealed Source3. Sealed Source in a Device4. Exempt Activity Permits

The Internal Radioisotope Permits are the method by which the Office of Risk Management (ORM) ensures compliance with the CNSC Acts, Regulation and Licences.


Corporate Oversight: Getting Started (1.2)

Approved by: ORM/lsp, jmm Current as of: 2018feb Page 2 of 2 Implementation Date: Oct. 2017

1.2.4 TRAINING: Training is a central component of the Radiation Safety Progam and it is mandatory for all individuals who work with radioactivity. The training is offered three times a year at the beginning of each semester. It is in‐class training and lasts 3 hours. The location alternates between Main Campus and Roger Guindon Hall (451 Smyth Road). The training covers:

• physical and biological characteristics of radiation;• risk analysis;• operational procedures; and• safe work practices.

To register for training, click on the following link: https://web47.uottawa.ca/en/lrs/node/1401

Before working with radioactive material, individuals must also complete a New User registration form which registers a user under a permit, records the type of radioactive materials to be used and documents the in‐lab practical training provided by the Permit Holder or his/her informed delegate.

Refresher training is typically required when the permit is renewed. Permits usually are issued for 4 years.

1.2.5 CANADIAN NUCLEAR SAFETY COMMISSION (CNSC) LICENSE The University of Ottawa has been issued a consolidated radioisotope license by the Canadian Nuclear Safety Commission (CNSC). This licence incorporates numerous conditions relating to radioactive material possession, use, disposal, importation and exportation. To maintain this licence, the University must ensure that activities involving radioactive substances and equipment are carried out in accordance with CNSC regulations and applicable conditions.

UO ‐ Office of Risk Management

RADIATION SAFTETY MANUAL

Operational Practices: Best Practices ‐ ALARA (2.1)

Approved by: ORM/lsp, jmm Current as of: 2018feb Page 1 of 3 Implementation Date: Oct 2017

ALARA

OVERVIEW:

ALARA is an acronym for “As Low As Reasonably Achievable”. It is a fundamental radiation safety principle for minimizing radiation exposure and releases of radioactive material, while taking into consideration economic and social factors. Not only is it a sound safety principle, it is a regulatory requirement for all radiation safety programs. At the University of Ottawa over 20 year period, the Radiation Safety Program has been based on the ALARA principle. Inventory control has kept the quantity and activity of radioisotopes to a minimum, users are knowledgeable, procedures are followed and no individual has ever received a dose close to the regulatory limit.

IMPLEMENTATION:

An effective ALARA based radiation safety program is only possible when a commitment to safety is made by all those involved and the principal should be used in all laboratory operations. Holistically as the Radiation safety Program, ALARA is ensured by the issuing of Internal Permits, training and authorizing users, approval of radioisotope purchases, assessing use and disposition records, contamination monitoring and radiation surveys, reviewing dosimetry exposure records, and decommissioning of permits, rooms and equipment.

In the laboratory, the ALARA principle can be followed by:

1) Designing the experiment/procedure so the lowest possible amount of radioactive material is usedand length of time in the radiation field is minimized.

2) Wearing dosimeters, if applicable, when working with radioactivity. (TLD are unable to detectradiation exposure to H‐3, C‐14, S‐35 or Ca‐45)

3) Providing bioassay samples when required. (Unbound I‐125 or I‐131 can accumulate in the thyroidIndividuals, at a single time, using more than 135 µCi (5 MBq) of I‐125 or I‐129 on the open bench ormore than 1.35 mCi (50 MBq) in a fumehood must participate in a thyroid monitoring program.)

4) Reporting incidents or unsafe practices to their supervisors and, if appropriate, the RadiationSpecialist

5) Being aware of potential radiation hazards, exposure levels and safety controls in the laboratory6) Knowing the operating and emergency procedures

MITIGATION OF EXTERNAL RADIATION EXPOSURES

There are three principles that can be used to limit to exposure to radiation: 1) Time – minimizing the time or exposure directly reduces the radiation dose2) Distance – doubling the distance between your body and the radiation source will divide the

radiation exposure by a factor of 4.3) Shielding – using an absorber such as Plexiglas for beta particles and lead for X‐rays and gamma rays

is an effective way to reduce radiation exposures





MITIGATION OF INTERNAL RADIATION EXPOSURES The following practices are effective for reducing potential internal exposures: 1) Good hygiene techniques that prohibit the consumption of food and drink in the laboratory, and the

control of personal gestures that involve “hand‐to‐mouth” contacts. 2) Frequent wipe tests and radiation surveys of work areas, refrigerators, hoods, sinks, phones and

computer keyboards. etc. 3) Control contamination with absorbent paper and spill trays, properly labelled waste containers,

equipment, etc. and prompt decontamination of any detected contamination. 4) Use fume hoods for materials which could become airborne (e.g., vapours, dust, aerosols, etc.) and

present an inhalation hazard to workers. 5) Use proper protective equipment such a disposable glove, safety glasses, lab coats, etc.

EXPOSURE MONITORING Doses are recorded on dosimeters provided by Health Canada Dosimetry Service. The dosimeter wearing period is 3 months. At the end of 3 months, they are returned to Health Canada for dose analysis (reading). Exposure reports are generated and sent by Health Canada before the next wearing period. If an individual receives an atypical dose (usually 0.6 - 0.8 mSv), the Radiation Specialist will contacted them by email and an investigaion will follow to determine the cause for the dose.

DOSE LIMITS Dose limits are set by the Canadian Nuclear Safety Commission (CNSC), Radiation Protection Regulations.

Maximum permissible annual dose to the whole body for the general public* is 1 mSv , for Nuclear Energy worker (NEW) it is 50 mSv Maximum permissible annual dose to extremities (hands, feet) for the general public* is 50 mSv , for Nuclear Energy worker (NEW) it is 500 mSv

*Under CNSC criteria, employees at uOttawa are classified as members of the general public.

RADIATION FIELDS Radiation surveys are generally performed by the Radiation Specialist during a Full laboratory inspection. If atypical radiation fields (usually 5 times above background) are measured, an investigation will be done.

ACTION LEVELS Action levels are tools used to ensure radiation dose limits are not exceeded. At the University of Ottawa, action levels are atypical doses or atypical radiation fields.

An atypical dose is usually 0.3 mSv over a 3 month dosimetry wearing period or a repeating dose that should a trend continue, the individual could exceed the public exposure limit of 1 mSv in a year.





Atypical radiation fields (usually 5 times above background) are assessed to determine their implications on doses received.

If an atypical dose or and atypical radiation field is reached, it will trigger an investigation to determine why the action level was reached and then determine the action required to remediate the situation so that the action level is not reached in the future.

REFERENCE: Keeping Radiation Exposures and Doses “As Low as Reasonably Achievable (ALARA) CNSC Regulatory Guide G0129


Operational Practices: Emergency Response (2.2)

Page 1 of 2 Approved by: ORM/lsp, jmm Implementation Date: Oct 2017

Current as of: 2018feb

EMERGENCY RESPONSE

The most difficult part of emergency response is deciding if it is an emergency, and the degree of importance. Always best to err on the side of caution. It is also important to plan the actions you would take for different accident scenarios before any accident occurs. If you require any additional information or guidance, please contact the permit holder or ORM.

PLANNING Before working with radioisotopes, plan what you would do if an accident happened. If you can think of how an accident might happen, you may be able to reduce the likelihood of such an event. For example, what would you do if an accident occurred while you were bringing a radioactive material through a public area, such as elevators or hallways?

FIRE If possible secure radioactive material that you are working with and then follow uOttawa Fire procedures:

Main Campus: http://www.uottawa.ca/are-you-ready/what-to-do/hazard-specific-procedures

Roger Guindon Hall: https://med.uottawa.ca/health-safety/emergency-procedures/fire-and-evacuation

OTHER HAZARDS There are often other hazards associated with radioisotope work. In the case of sealed sources, these may be electrical or physical. In the case of open source work, there is often a biological or chemical hazard associated with the radioisotope. Develop a plan to deal with these hazards before you begin your radioisotope work.

There may be hazards specific to the radioisotope and its chemical form. These hazards may include volatility or reactivity as well as the type of radiation emitted. When planning for, or responding to, an emergency, keep these hazards in mind. For example, unbound radioiodines pose an inhalation hazard; 32P radiation is damaging to the eyes.

SEALED SOURCE Any incident involving a sealed source must be reported to the ORM. Any malfunctions of equipment that contain a sealed source must also be reported to the ORM.

For sealed sources that require leak- testing (acitvity > 50 MBq), if the leak testing results indicate a leakage of 200 Bq or more, the following steps must be taken:

http://www.uottawa.ca/are-you-ready/what-to-do/hazard-specific-procedureshttps://med.uottawa.ca/health-safety/emergency-procedures/fire-and-evacuation





(a) discontinue using the sealed source or shielding;

(b) discontinue using the radiation device in which the sealed source or shielding is located or may have been located;

(c) take measures to limit the spread of radioactive contamination from the sealed source or shielding; and

(d) immediately after complying with paragraphs (a) to (c), notify ORM who will notify the CNSC





OPEN SOURCE Since the scenarios of a spill are numerous and the potential impact broad ranging, each scenario must be assessed independently. General guidelines can be found in the following section, “Spill Response Procedure” and in the CNSC poster entitled "Radioisotope Safety – Spill Procedures" (INFO-0543(E)). This poster should be posted in your laboratory with the name and phone number for the responsible contact person in the space provided.

ORM provides additional support by addressing spill response during their training sessions and private consultation. Training videos are also available from ORM which address the clean-up and decontamination procedures.

Any major spill must immediately be reported to Protection Services. For additional assistance and clarification contact ORM.

Major spills involve more than 100 exemption quantities, or contamination of personnel, or release of volatile radioactive material.




EMERGENCY RESPONSE

The most difficult part of emergency response is deciding if it is an emergency, and the degree of importance. Always best to err on the side of caution. It is also important to plan the actions you would take for different accident scenarios before any accident occurs. If you require any additional information or guidance, please contact the permit holder or ORM.

PLANNING Before working with radioisotopes, plan what you would do if an accident happened. If you can think of how an accident might happen, you may be able to reduce the likelihood of such an event. For example, what would you do if an accident occurred while you were bringing a radioactive material through a public area, such as elevators or hallways?

OTHER HAZARDS There are often other hazards associated with radioisotope work. In the case of sealed sources, these may be electrical or physical. In the case of open source work, there is often a biological or chemical hazard associated with the radioisotope. Develop a plan to deal with these hazards before you begin your radioisotope work.

There may be hazards specific to the radioisotope and its chemical form. These hazards may include volatility or reactivity as well as the type of radiation emitted. When planning for, or responding to, an emergency, keep these hazards in mind. For example, unbound radioiodines pose an inhalation hazard; 32P radiation is damaging to the eyes.

SEALED SOURCE Any incident involving a sealed source must be reported to the ORM. Any malfunctions of equipment that contain a sealed source must also be reported to the ORM.

For sealed sources that require leak‐ testing (acitvity > 50 MBq), if the leak testing results indicate a leakage of 200 Bq or more, the following steps must be taken:

(a) discontinue using the sealed source or shielding;

(b) discontinue using the radiation device in which the sealed source or shielding is located or may have been located;

(c) take measures to limit the spread of radioactive contamination from the sealed source or shielding; and

(d) immediately after complying with paragraphs (a) to (c), notify ORM who will notify the CNSC




OPEN SOURCE Since the scenarios of a spill are numerous and the potential impact broad ranging, each scenario must be assessed independently. General guidelines can be found in the following section, “Spill Response Procedure” and in the CNSC poster entitled "Radioisotope Safety – Spill Procedures" (INFO‐0543(E)). This poster should be posted in your laboratory with the name and phone number for the responsible contact person in the space provided.

ORM provides additional support by addressing spill response during their training sessions and private consultation. Training videos are also available from ORM which address the clean‐up and decontamination procedures.

Any major spill must immediately be reported to Protection Services. For additional assistance and clarification contact ORM.

Major spills involve more than 100 exemption quantities, or contamination of personnel, or release of volatile radioactive material.


Operational Practices: Emergency Response ‐ Spill Response Procedure (2.2.1)


SPILL RESPONSE PROCEDURE

SPILL RESPONSE PROCEDURE

For major spills (> 100 times exception quantity, or contamination of personnel, or release of volatile), immediately inform ORM

1. Notify all individuals in the immediate area that a spill has occurred.

2. Increase distance from the spill. If the spill is severe, this may require evacuating the area.

3. If evacuation is required, lock and sign door. The warning sign should include your name, as well as a location of spill and time of return.

4. Limit access to only those individual responding to the spill.

5. If personal contamination has occurred, gently wash skin with a mild soap and tepid water.

6. If personal (skin) contamination has occurred, immediately contact ORM

If safe to do:

1. Contain the spill with absorbent material (paper towels).

2. Obtain any additional supplies and/or personal protective equipment (overalls, shoe

3. Push spill toward its centre. Clean from outside to inside. Collect all contaminated material in one appropriately labelled bag.

4. Decontaminate area with appropriate solutions (keep in mind biological or chemical

5. If fixed contamination above twice background remains, contact the ORM.

Leaving the scene after cleaning up:

1. Monitor self (especially feet, hands and lab coat) for contamination.

2. Leave lab coat behind if contaminated. Remove and take dosimetry badge to avoid erroneous readings.

UO ‐Office of Risk ManagementRADIATION SAFTETY MANUAL

Operational Practices: Dosimetry (2.3)

Page 1 of 3Approved by: ORM/lsp, jmm Implementation Date: Oct 2017


DOSIMETRY Exposure to radiation must be closely monitored to ensure that no one receives an exposure which could have a potentially adverse health effect. In recognition of this, CNSC has set dose limits for members of the general public and nuclear energy workers. The following table outlines those limits:

Dose Limits Assigned by CNSC

Body Part Member of General Public Nuclear Energy Worker

Whole body, gonads, bone marrow 1 mSv 50 mSv

Skin, thyroid, bone 50 mSv 500 mSv

Tissues of hands, feet and forearms 50 mSv 500 mSv

A nuclear energy worker is defined as any individual in the course of their work who would exceed the dose limit of a member of the general public. For an individual to be identified as a nuclear energy worker the following information will be assessed: research design, historical records and anticipated dose. If deemed as a nuclear energy worker the individual will be formally required to sign the appropriate documentation. It is important that ORM be informed of any change in experimental design that could result in an exposure above the general public limits.

2.3.1 DOSIMETERS The dosimeters used by the University can be thermoluminescent dosimeters (TLD) called Next Gen thermoluminescent or the newer, InLight Nova dosimeters which use optically stimulated luminescence (OSL) technolgy. The dosimeters can be whole body badges, wrist extremity badges or rings. All individuals who are exposed to radiation, and who may receive a dose will be issued a dosimeter. ORM may also elect to monitor (short or long term) individuals who do not directly work with radiation but may be in proximity to radioactive sources. These individuals include support staff, contractors, and trades personnel. The dosimetry requirements for authorized users are listed on the second page of the Internal Radioisotope Permit. The type of dosimeter is also listed on this page, i.e. whole body, extremity or ring badge. Note, CNSC requires a ring dosimeter to be worn by a person who handles a container whose content is 50 MBq or greater of phosphorous‐32, samarium 153, strontium 89, or Yttrium 90.

It is important to note that hydrogen‐3 and carbon‐14 emit such weak beta particles that they can not penetrate the shielding of the badge to be detected. The shielding incorporated into the dosimeter badge is intentionally designed to mimic the natural shielding provided by your skin, fat and other organs. Thus a dosimeter will not be assigned to those individuals who use these radioisotopes. Although the risk of external exposure is minimal, proper procedures must be followed to avoid an internal exposure due to consumption, absorption etc..





CNSC has produced a poster to assist you in storing and wearing your dosimeter badge correctly. This poster can be found on the Radiation Safety Web site.

Link to: CNSC Poster: Proper Care and Use of Personal Dosimeters

Note, dosimeters must only be worn in the work environment. They must not be worn outside the work environment such as when undergoing medical procedures involving radiation, as this may cause the dosimeter to register a non‐occupational exposure.

2.3.2 DOSIMETRY SERVICE Dosimetry service to the University of Ottawa is provided by Health Canada's National Dosimetry Service (NDS). This service is registered and approved by CNSC. To enrol in the NDS the following information must be submitted: Name, Sex, Date of Birth, Place of Birth and Social Insurance Numbers. Individuals who register to work in a radioactive use laboratory and fill out the "New User Registration Form" will automatically be issued a dosimeter if required. For other non‐users who wish to have a dosimeter, contact ORM and they will issue a badge if it is deemed necessary.

Through the NDS service, an individual's dose is tracked for life. An individual can change employers numerous times or even have a hiatus from a radiation related employment and his/her dose record will still follow the individual. Because of the number of individuals tracked in this system, the system requires social insurance numbers to ensure the doses are correctly assigned to the individuals.

2.3.3 DOSE RECORDS Dose records are sent to ORM every three months, where they are reviewed for any abnormal or atypical results. If an atypical dose is reported, ORM will notify you by email and follow‐up with you to determine if the exposure reading represents a personal dose due to experimental design, a singular incident, or a non‐personal dose due to storage practices or damage. ORM also monitors the readings to ensure an individual's dose does not exceed the CNSC dose limits. Should a reading approach the limit, the experimental design and your work scheduling will have to be reviewed and modified if necessary. Should you wish to see your acummulative dose, please feel free to contact ORM. For complete dose histories, contact Health Canada National Dose Resgistry and complete the Employee's Dose History Summary (EDHS) Request Form. See following link for a copy of the form: https://www.canada.ca/en/health‐canada/services/environmental‐workplace‐health/occupational‐health‐safety/occupational‐radiation/national‐dose‐registry/national‐dose‐registry‐employee‐dose‐history‐summary‐edhs‐request‐form.html

2.3.4 THYROID MONITORING Iodine is a health risk since it can easily concentrate in the thyroid if the appropriate containment procedures are not used. In the past, bound iodine was thought to be relatively safe since it was not considered volatile, however interactions with certain chemicals can cause it to become volatile. Currently, CNSC does not differentiate between bound or unbound iodine and requires thyroid monitoring if there is a potential of a spill. In addition, users will require thyroid monitoring if they use a single 24 hour period more than 2 MBq (0.054 mCi) of iodine‐125 or iodine‐ 131 on the open bench, more than 200 MBq (5.41 mCi) in a fume hood or more than 20 GBq (541 mCi) in a glovebox.





If you plan to use I‐125 or Iodine‐131, contact ORM since a thyroid monitoring program will need to be created and purchases will not be approved until the program is established.

2.3.5 PREGNANCY All workers at the University are considered to be members of the general public with regards to the maximum permissible radiation dose and as such, there is no difference between the maximum amounts or radioactivity a pregnant work can receive versus a non‐pregnant worker.

However, individual must notify the Radiation Specialist and their permit holder/supervisor as soon as they suspect a pregnancy. If necessary, the Radiation Specialist will keep this information in confidence. Depending on the exposure risk in the laboratory, the worker may be re‐assigned tasks and offered participation in a special monthly dosimetry service. Any specific concerns should be brought to the attention of the Radiation Specialist or the supervisor.





DOSIMETRY

Exposure to radiation must be closely monitored to ensure that no one receives an exposure which could have a potentially adverse health effect. In recognition of this, CNSC has set dose limits for members of the general public and nuclear energy workers. The following table outlines those limits:

Dose Limits Assigned by CNSC Body Part Member of General Public Nuclear Energy Worker

Whole body, gonads, bone marrow 1 mSv 50 mSv

Skin, thyroid, bone 50 mSv 500 mSv

Tissues of hands, feet and forearms 50 mSv 500 mSv

A nuclear energy worker is defined as any individual in the course of their work who would exceed the dose limit of a member of the general public. For an individual to be identified as a nuclear energy worker the following information will be assessed: research design, historical records and anticipated dose. If deemed as a nuclear energy worker the individual will be formally required to sign the appropriate documentation. It is important that ORM be informed of any change in experimental design that could result in an exposure above the general public limits.

2.3.1 DOSIMETERS The dosimeters used by the University can be thermoluminescent dosimeters (TLD) called Next Gen thermoluminescent or the newer, InLight Nova dosimeters which use optically stimulated luminescence (OSL) technolgy. The dosimeters can be whole body badges, wrist extremity badges or rings. All individuals who are exposed to radiation, and who may receive a dose will be issued a dosimeter. ORM may also elect to monitor (short or long term) individuals who do not directly work with radiation but may be in proximity to radioactive sources. These individuals include support staff, contractors, and trades personnel. The dosimetry requirements for authorized users are listed on the second page of the Internal Radioisotope Permit. The type of dosimeter is also listed on this page, i.e. whole body, extremity or ring badge. Note, CNSC requires a ring dosimeter to be worn by a person who handles a container whose content is 50 MBq or greater of phosphorous‐32, samarium 153, strontium 89, or Yttrium 90.

It is important to note that hydrogen‐3 and carbon‐14 emit such weak beta particles that they can not penetrate the shielding of the badge to be detected. The shielding incorporated into the dosimeter badge is intentionally designed to mimic the natural shielding provided by your skin, fat and other organs. Thus a dosimeter will not be assigned to those individuals who use these radioisotopes. Although the risk of external exposure is minimal, proper procedures must be followed to avoid an internal exposure due to consumption, absorption etc..





CNSC has produced a poster to assist you in storing and wearing your dosimeter badge correctly. This poster can be found on the Radiation Safety Web site.

Link to: CNSC Poster: Proper Care and Use of Personal Dosimeters

Note, dosimeters must only be worn in the work environment. They must not be worn outside the work environment such as when undergoing medical procedures involving radiation, as this may cause the dosimeter to register a non‐occupational exposure.

2.3.2 DOSIMETRY SERVICE Dosimetry service to the University of Ottawa is provided by Health Canada's National Dosimetry Service (NDS). This service is registered and approved by CNSC. To enrol in the NDS the following information must be submitted: Name, Sex, Date of Birth, Place of Birth and Social Insurance Numbers. Individuals who register to work in a radioactive use laboratory and fill out the "New User Registration Form" will automatically be issued a dosimeter if required. For other non‐users who wish to have a dosimeter, contact ORM and they will issue a badge if it is deemed necessary.

Through the NDS service, an individual's dose is tracked for life. An individual can change employers numerous times or even have a hiatus from a radiation related employment and his/her dose record will still follow the individual. Because of the number of individuals tracked in this system, the system requires social insurance numbers to ensure the doses are correctly assigned to the individuals.

2.3.3 DOSE RECORDS Dose records are sent to ORM every three months, where they are reviewed for any abnormal or atypical results. If an atypical dose is reported, ORM will notify you by email and follow‐up with you to determine if the exposure reading represents a personal dose due to experimental design, a singular incident, or a non‐personal dose due to storage practices or damage. ORM also monitors the readings to ensure an individual's dose does not exceed the CNSC dose limits. Should a reading approach the limit, the experimental design and your work scheduling will have to be reviewed and modified if necessary. Should you wish to see your acummulative dose, please feel free to contact ORM. For complete dose histories, contact Health Canada National Dose Resgistry and complete the Employee's Dose History Summary (EDHS) Request Form. See following link for a copy of the form: https://www.canada.ca/en/health‐canada/services/environmental‐workplace‐health/occupational‐health‐safety/occupational‐radiation/national‐dose‐registry/national‐dose‐registry‐employee‐dose‐history‐summary‐edhs‐request‐form.html

2.3.4 THYROID MONITORING RadioIodine is a health risk since it can easily concentrate in the thyroid if the appropriate containment procedures are not used. Refer to the section, In CNSC regulatory document RD‐58, the thyroid monitoring requirements are focused on volatile (unbound)radioiodine due to the high risk of this form to concentrate in the in the thyroid. Currently, the Univeristy of Ottawa`s Nuclear substance and Radiation Devices liicense 07152‐1‐23.0 does not differentiate between bound or





unbound iodine and requires thyroid monitoring of individuals if they use a single 24 hour period more than 2 MBq (0.054 mCi) of iodine‐125 or iodine‐131 on the open room, more than 200 MBq (5.41 mCi) in a fume hood or more than 20 GBq (541 mCi) in a glove box. Thyroid monitoring is also required if individuals are involved in a spill of greater than 2 MBq or if an individual has external (skin) contamination. With the external (skin) contamination, no quantity of radioactivity (MBq) is specified and since there is no activity specified, procedures for thyroid monitoring must be in place for any use of I‐125 or I‐131.

For radioiodine Users that will use greater than 2 MBq in the open room, more than 200 MBq in a fumehood and more than 20 GBq in a glove box, a baseline thyroid reading will need to be taken before work is started. This is a “best practice” and not a regulatory requirement. Then thyroid monitoring is required the day after handling and 5 days after.

For all users who are involved in a spill or have external (skin) contamination, contact ORM or Radiation Specialist immediately ([email protected], ext. 3057 or 8081) and monitoring will be arrange for the following day and 5 days after.

If you plan to use I‐125 or Iodine‐131, contact ORM since a thyroid monitoring program will need to be re‐instated and purchases will not be approved until the program is established.

All users who plan to use radioiodine compounds should read the Safe Work Practices for Radioiodine which is in section 2.16.1 of this manual.

2.3.5 PREGNANCY All workers at the University are considered to be members of the general public with regards to the maximum permissible radiation dose and as such, there is no difference between the maximum amounts or radioactivity a pregnant work can receive versus a non‐pregnant worker.

However, individual must notify the Radiation Specialist and their permit holder/supervisor as soon as they suspect a pregnancy. If necessary, the Radiation Specialist will keep this information in confidence.

Depending on the exposure risk in the laboratory, the worker may be re‐assigned tasks and offered participation in a special monthly dosimetry service. Any specific concerns should be brought to the attention of the Radiation Specialist or the supervisor.



Operational Practices: Inventory (2.4)


INVENTORY

One of CNSC primary requirements, is inventory control. Management and users must maintain accurate up‐to‐date records of all radioactive material, and ensure that the material is held in a secure fashion. Inventory must be tracked from purchase right through to disposal. This tracking is termed a cradle to grave management process. The acquisition, transfer and disposal records of all types of radioactivity, an open source, sealed source or sealed source in a device, must be maintained.

Inventory tracking for all radioactive materials begins with the purchase order form and all purchase forms must be processed through a designated purchasing department so that the purchase order is approved by ORM. It is important that each section of the form be completed and that the information is accurate. If the wrong information is given for a sealed source or a sealed source in a device then the actual permit will be wrong and the error will most probably be caught quickly. If the wrong activity or wrong radioisotope for an unsealed source is given then the wrong information will be logged into the ORM database and the error will not be caught until the lab verifies its records with the ORM inventory records. It may take considerable time and effort to correct the error and the onus is on the lab to prove that the ORM database is wrong.

It is also important that ORM is informed of any transfers so that inventory records are adjusted to ensure accuracy.

Note, this inventory control also incudes location of radioactive material. All radioactive material including sealed sources and sealed sources in devices may only be used and stored in the authorized locations that are listed on the Permit Holder’s Permit. Any movement to other locations must first be authorized by ORM and permit updated to refect location changes before radioactive material is moved.

For unsealed source permits, at least once a year, the Permit Holder will be asked to verify their inventory with the ORM inventory and it is vital that this verification is a physical verification. This means that the information on each stock vial must be compared to the information listed on the ORM inventory listing. It is strongly suggested that the purchase order number be written or attached to the stock vial since it is the unique identify for the radioactive substance. Placing the purchase order number on the stock vial will make the inventory verification process much easier.

As the nature and use practices of the different types of radioactive material varies, the inventory management system is adapted to meet the needs of each type. For open source material, a dedicated inventory form, Use and Disposition, is used to track each sample. With each new open source sample, a Use and Disposition form is started and kept in the Laboratory. Records can be hard copies that are kept in the Radiation Records Binder or electronic and kept in Radiation Record’s files. All usage and disposals are logged on this form. Once the open source sample has been completed used up (“finished”), the information on Use and Disposition sheet is transcribed to the electronic excel Use and Disposition which is then sent to ORM. ORM updates the ORM database and the sample is removed from the Permit Holder’s inventory. For sealed sources and sealed sources in a devices, the inventory is



Operational Practices: Inventory (2.4)


tracked by incorporating the serial number of each source into the internal radioisotope permit. To dispose of a sealed source, ORM must be contacted and a transfer form completed to comp document the method of disposal (to ORM or a third party such as a licensed radiation disposal any).

Find the Use and Disposition Form in Section 2.16 ‐ Forms.

* Note: Immediately upon completion of this form, a copy must be sent to ORM.

UNIVERSITY OF OTTAWA

RADIATION SAFETY MANAUAL

Operational Practices: Purchasing (2.5)


PURCHASING

One of the primary controls the University has in ensuring the necessary control of radioactive material is its purchasing process. The University must ensure only those individuals who have been approved by the Radiations Safety Committee are authorized to purchase radioactive material; and only those radioisotopes and activities authorized may be purchased. These limits are set by taking into consideration the researchers needs, and the University of Ottawa's Nuclear Substances and Radiation Device Licence. ORM acts on behalf of the Committee and reviews all purchases prior to issuing an approval.

As the purchasing process may at times be just as simple as completing a Radioactive Purchase Requisition form or, it can also become quite complex as when negotiating a contract. The significance and impact of purchasing contracts are discussed in Section 2.5.1, “Purchasing and Shipping Factors”. The Purchasing Procedure which defines the roles and responsibilities of each party and the procedure to be followed can be found in Section 2.5.4, “Purchasing Procedure” and a dedicated requisition form can be found in Section 2.16, “Forms”.


Operational Practices: Purchasing ‐ Purchasing and Shipping Factors (2.5.1)


PURCHASING, SHIPPING AND RECEIVING FACTORS

This document will provide an overview of the issues which must be considered when purchasing and shipping radioactive material (RAM). Inherently the successful receipt/delivery of your purchase or transfer of RAM is dependent upon the awareness level of those individuals involved, to the factors which determine or influence travel arrangements. This guide will outline the issues in terms of: regulatory control, purchasing and shipping issues.

See sections on Purchasing, Shipping and Receiving for more detailed information.

REGULATORY CONTROL ISSUES: The Canadian Nuclear Safety Commission (CNSC) through the issuance of a Nuclear Substances and Radiation Devices Licence, the Canadian Nuclear Safety Control Act and associated regulations control the purchase, possession and transfer of radioactive material within Canada. For the University of Ottawa this means not only does the consolidated licence dictate what radioisotopes may be purchased but also the activity and the form (open or sealed). CNSC has delegated the University the responsibility of regulating individual permit holders as to what they may purchase and transfer. Hence RAM may only be purchased in accordance to in‐house permit conditions and with authorization by ORM. In addition, RAM must only be offered for shipment once approved by ORM. This ensures the University of Ottawa remains in compliance with the CNSC Act and regulations.

Although CNSC may take the primary lead in regulating RAM, it is by no way the only regulatory body concerned with the security of RAM, especially during transit. Transport Canada (TC) also regulates radioactive material under the Transportation of Dangerous Good Act and on the international front, the International Atomic Energy Association (IAEA) provides guidance and control. When air carriers are used the International Air Transport Association (IATA) regulates what conditions must be met. Finally most countries have their own national agencies which regulate RAM and may dictate the terms of transfer.

From this brief overview of the main agencies concerned with the security of RAM one can appreciate how complicated the receipt of RAM may become. It is important to implement and follow the appropriate in‐house procedures and address the need for a contingency plan to be in place should an incident occur in transit, or at the point of receipt. To address these issues, one must first examine what are the roles and responsibilities of those involved from the start of contract negotiation for the purchase of the RAM to the actual transfer and receipt of this material.

PURCHASING ISSUES: The role of the contract terms is often underestimated, yet they play a critical role in the receipt of the RAM and the level of compliance achieved. In addition to defining the material that is to be purchased, there is often a reference to the International Chamber of Commerce ‐ Incoterms 2010. These international procurement rules clearly states what are the roles and responsibilities of the buyer and seller. Specifically referenced are those who are responsible for: obtaining insurance (liability and




product), receiving importation authorization, and paying duty and freight forwarding costs. Also, defined is the time when the buyer officially take possession of the goods and accepts all risk and liability. It is important to note under some Incoterms 2010, that “time” could be at the airport where the supplier releases the goods to the carrier. The need for specific documentation such as quality assurance, source integrity verification (leak testing) etc must also be stated at the time of contract negotiation. If these issues are not clearly understood or negotiated prior to the contract being signed, there may be no opportunity to re‐negotiate them once the oversight has be identified. In the most unfortunate circumstance the delivery of the goods may be delayed or even prevented if these issues are not addressed. For these reasons, it is the role of Material Management Service to set and monitor all contracts.

SHIPPING AND RECEIVING ISSUES: It is important to note that the issues identified in the previous section also relate to shipping arrangements.

When goods enter Canada there is a need to have the goods clear customs. The University of Ottawa has engaged a brokerage company to facilitate the clearance of the majority of shipments through customs. They require specific information to be provided by the seller, such as commercial invoices/Proforma invoices, bill of lading. In addition, Canada Customs and Revenue Agency will require documentation that the receiver is authorized by CNSC to possess the radioactive material.

Should the shipment be sent from the University of Ottawa to another party (transferred), the same need for verification of authorizations must be fulfilled. ORM must ensure that the recipient institution and the individual are: authorized, aware of the travel arrangements, and will confirm receipt of shipment. In preparing the actual shipment, the RAM must be assessed using a variety of criteria (radioisotope, activity, dose rate, contamination limits etc.) to determine under what classification it will be shipped. This information is then used to confirm that all packaging, labeling, and documentation requirements are met for each of the regulatory bodies (CNSC, TC, IAEA, IATA). International shipments may also engage additional requirements set by the recipient country (ie. USA ‐ Department of Homeland Security).

Finally, the ultimate control over shipping lie with the carrier. The carrier will route or reroute any of its transport vehicles, as it deems necessary. Thus a direct flight may actually be a multiple stage travel route, with a number of different carriers (and travel forms) being used, through a number of different countries. It is important to be aware these possible changes, as it increases the risk of the package being held up in transit; especially as an individual pilot has final say on what he is prepared to transport. A lack of a comma on documentation can stop a shipment at any point.

CONCLUSION: As seen in this brief review, there are numerous issues which must be considered when purchasing, shipping or receiving RAM. It is a heavily regulated area with a high degree of risk associated with the process. For this reason the ORM staff play a key role in monitoring and ensuring risks have been




identified and minimized. Should you anticipate engaging any of this process, inform ORM early in the process so that time is available to resolve any possible issues.


Operational Practices: Purchasing – Purchasing Procedure (2.5.2)


PURCHASING PROCEDURE

OVERVIEW:

To ensure the appropriate control systems are in place with regards to the purchases of radioactive material, the University of Ottawa has a purchasing procedure. This procedure will ensure that all material purchased is compliant, not only with regards to the University’s Canadian Nuclear Safety Commission (CNSC) ‐ Nuclear Substances and Radiation Devices Licence, but also individual permits. The CNSC expects the purchase control of:

a) open source of radioactive materialb) sealed sources of radioactive material, andc) sealed sources incorporated in a device (i.e., gas chromatographs and liquid scintillation

counters).

To ensure inventory control and compliance, all radioactive material be pre‐approved by ORM prior to being ordered. Failure to do so, would be viewed most seriously not only by the University senior administration but also by CNSC.

Due to the complexity of international shipments and the multiple regulations that must be considered, the University has to be diligent when ordering from external suppliers. Issues that must be considered and incorporated into contracts are international trading terms, integrity issues, packaging requirements, travel arrangements and designation of carriers, brokers, freight forwarders etc. For this reason the time requirements associated with international purchases can be considerably longer than standard shipments.

ROLES AND RESPONSIBILITIES:

Principal Investigators: ● ensure their current permit authorizes the purchase of the radioactive material and the

requested activity. ● complete the “Radioisotope Purchase Requisition Form” (available on the ORM web site:

https://orm.uottawa.ca/programs/radiation) ● follow “Procedures for Ordering Radioactive Material”

ORM: ● ensure that the radioactive material purchase process will be in compliance with CNSC’s

regulations● approve all Radioisotope Purchase Requisition Forms that meet necessary criteria● forward the completed form to purchasing departments by agreed upon time lines.




Purchasing Agent: ● receive and place the approved purchase.

CRITERIA FOR PURCHASE APPROVALS:

The main criteria for approval is that the purchase complies with CNSC requirements. Other criteria will also be used to ensure the integrity of the control system. They are:

● permit holder is authorized to possess the material ordered● the submission is complete (The purchase order number is a critical factor for the

inventory control management system, and therefore must be on the order form.)● the submission has been received before 1:00 p.m. on Tuesday or Thursday. If the order is

received by ORM personnel after 1:00 p.m. it will be approved on the following Tuesday orThursday.

● international shipments will not be processed with the above mentioned time lines beinghonoured, due to the complexity and regulatory requirements. Note, that ORM does not havethe ability to control timely receipt of information provided by external parties.

PROCEDURE:

1. All radioactive material (open sources, sealed sources and sealed sources incorporated in adevice) must be ordered using the ‘Radioisotopes Purchase Requisition’ form.

2. Each purchase requisition must have all the required information. Should multiplecompanies be involved in the ordering, production and transfer of the radioactivematerial, all companies must be listed, with their addresses, and the name andtelephone/fax/email of the contact person. This situation occasionally occurs whenordering sealed sources, ie the company selling the material may be in one country, yet thematerial is produced and shipped from another.

3. All requisitions must be signed by the principal investigator or delegate.

4. Once completed, the purchase requisition must be sent to the purchasing department(MedPurch for RGN and Science Stores for Main Campus)

5. Purchasing department assigns a Purchase order number (PO#) and then forwardspurchase requisition to the ORM Office ([email protected]) by email for approval.(Science Stores also cc’s email to requestor.)




6. Radiation Specialist will review the requisition. If the order is incompliance with the permitholder’s permit and the CNSC license, it will be approved. Purchase requisitions for aradioisotope not listed, or in excess of the associated use limit on an individual permit will notbe processed. If this occurs the permit holder will be informed of the problem.

7. Upon approval by the ORM Office, the purchase requisition will be emailed back to thepurchasing department and the material will be ordered.

For Science Stores, the email will also be cc’d to requestor.

For MedPurch, the approved purchase requisiton will be attached to the requestor’sMedPurch page.

IMPORTANT: Requestors must make note of the PO# as it is the unique identifier for the radioactive material and it is used to track the material from “cradle to grave”. Once the radioactive material is received in the lavoratory, a “Use and Disposition form” must be started for the material and the PO# must be insterted on this form.


Operational Practices: Purchasing – Shipping (2.5.3)


SHIPPING

The shipping in the context of this manual, is the act of transporting radioactive material. It involves packing the material, arranging the transportation and ensuring compliance with regulations. For shipping radioactive material within Canada, the primary regulation is CNSC's Packing and Transport of Nuclear Substances Regulations (PTNS). However other regulations may also be applicable. If the radioactive medium (eg. Benzene) is a Hazardous Substance then Transport Canada's Transportation of Dangerous Goods (TDG) will apply. If the transport arrangement is by air, the International Air Transport Association (IATA) may applicable. If the transport will cross international borders, the International Atomic Energy Association (IAEA) will need to be consulted. In addition, most of these regulations also stipulate receiving requirements. Needless to say the task of shipping can become quite complex and for non‐routine shipments, ORM must be consulted.

Inherently, the primary concern for the shipping of radioactive material is to ensure the design and integrity of the radioactive material and associated packaging is such that it will not result in a release of radioactive material or an unexpected exposure during transit. Appropriate documentation and labeling assists in informing others of any potential risk. Should any damage of the packaging occur during transit it is the responsibility receiver to monitor the package (dose rate and contamination) and report any incident to CNSC. This reporting becomes critical if there exist a potential for exposure of individuals, or contamination of multiple sites. For this reason ORM must be contacted should a damaged package be received. ORM will investigate and inform CNSC if required.


Operational Practices: Purchasing ‐ Receiving (2.5.4)


RECEIVING

Radioactive packages are first received by the person/s who receive all deliveries, usally “Shipping and Receiving Departments”, and then the radioactive packages are picked‐up by the authorized radioactive User. Section A provides the procedures for the “Shipping and Receiving Department” while Section B provides the procedures for the Radioactive User. A flow chart for reporting suspicious or damaged packages is in Section C.

SECTION A

• Ensure all individuals receiving radioactive material have been trained in TDG for Class 7Receive Package

• Ensure all deliveries are scheduled during working hours. If for an exceptional circumstance, ashipment is to arrive after working hours, have a specific storage loca

RADIATION SAFETY MANUAL - Office of Risk Management · 2018-03-22 · UO- Office of Risk Management...

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