The objective of this plan is to provide the necessary procedures, guidance, and information for the safe use of radioactive materials at St. Mary’s University. While this plan does not include all radiation safety requirements, it does provide a detailed guide for users of radioactive materials. At present, the University holds no radioactive material licenses with the State of Texas. Only exempt amounts of radioactive material may be used on campus. A detailed list of exempt sources can be found at the United States Nuclear Regulatory Commission (USNRC) Regulation 10 CFR § 30.70 Schedule A – exempt concentrations and the Texas Department of State Health Services, 25 TAC § 289.251(l)(1). Those interested in reviewing more complete code requirements are encouraged to contact the University’s Radiation Safety Officer (RSO).
The Radiation Safety Officer (RSO) has the broad responsibility for monitoring, updating, and determining the degree of compliance with established regulations, policies, and practices regarding the license, purchase, shipment, use, monitoring, disposal, and transfer of radioactive material at St. Mary’s. The RSO will periodically provide a comprehensive briefing on the status of the Radiation Safety Program to the University Safety Committee.
The following criteria are used as a guide in approving qualified personnel for specific uses of radioactive materials. A “user” referred to in these criteria means a qualified person performing experiments using radioactive materials. Guidelines are also included for “Maintenance and Janitorial Workers” performing their duties in radiation areas.
Each Principal Investigator (PI) and additional users of radioactive materials:
The RSO and University Safety Committee will approve proposals only if convincing evidence is provided that the user is competent in performing all applicable phases of the proposed experiments. If, after reviewing the proposal and supporting information, the RSO and/or Committee members have questions about the safety of the proposed use, they may require:
To be designated as a Principal Investigator, an individual must have the approval of the RSO and the University Safety Committee. In granting this approval the following criteria, in addition to those cited elsewhere in this section, shall be used as a guide in evaluating the person. A Principal Investigator:
The position of Radiation Worker is established primarily for personnel who will be working with very low levels of radioactive materials involving minimal hazards. Direct supervision is required. Direct supervision means that the supervisor (PI) must work closely with the individual, physically demonstrate the procedures, and give instruction on the hazards of the experiment. The supervisor should be physically present, unless convinced that the worker understands the procedures and can safely perform the assigned duties. The supervisor should be readily available for the worker to contact in case of need. If the person has had no experience working with radioactive materials, that person, before conducting radioactive experiments, must work as a trainee for an initial period with the supervisor physically present. The trainee should make trial runs, when necessary, using non-radioactive materials until the worker can safely conduct or assist in conducting the radioactive experiments. Such a trainee should also take the Radiation Safety Short Course as soon as it is next offered. Since the short course is offered no more than once a semester, the trainee should be scheduled for one-on-one training with radiation safety personnel as soon as possible. This one-on-one training will usually consist of the trainee viewing radiation safety videotape and a question-and-answer session with the RSO present. Refresher training is required of every individual at intervals not to exceed seven years.
Maintenance personnel who are required to work in laboratories where possible radiation hazards exist, must be informed of those hazards and be supervised when necessary. The PI shall notify the RSO before maintenance personnel start work on such projects so that proper safety will be provided. The following examples are types of projects that should be reported to the RSO before work is begun:
Janitorial workers must be apprised of any radiation hazards present and the meaning of warning signs and labels. The RSO can provide this training whenever necessary.
All radioactive material shipments shall be coordinated by the RSO. All shipments, packaging, and transportation of radioactive materials from or by the University to outside agencies shall comply with the requirements of 25 TAC § 289.257, the Department of Transportation, and all other applicable state and federal regulations.
Requisitions for radioactive materials shall not be submitted if such materials and quantities, plus the materials and quantities on hand, exceed those listed on the PI’s proposal as approved by the RSO and the University Safety Committee. All incoming packages of radioactive materials shall first be delivered to the RSO’s office. The package will be checked for integrity, monitored in accordance the State of Texas Standards for Protection Against Radiation, and delivered to the appropriate laboratory.
Transfers of radioactive materials to other facilities must be coordinated with the RSO. Such shipments must be properly packaged, labeled and wipe tested, as necessary. The RSO must have a copy of the recipient’s license number as proof that the individual is authorized to receive the material.
When transporting radioactive material, particularly radioactive liquids in glass containers from one laboratory to another, a secondary container; such as, Styrofoam, cardboard, rubber, or metal must be used. When millicurie (mCi) amounts of radioactive solutions are transported, enough absorbent packing material shall be used to ensure that all the liquid is absorbed in case of breakage or leakage. Vehicles used for transporting these radioactive materials should be checked for contamination after use and decontaminated, if necessary.
Each Principal Investigator that uses radioactive material (licensed and exempt) is required to keep an inventory of radioactive materials in their possession. Inventory reports should be submitted annually to the RSO at the beginning of the fiscal year (June 1). Serious delinquencies may result in punitive action by the University Safety Committee. Upon request, the RSO can provide radioactive material inventory forms. The inventory forms are for reporting the amounts of each radionuclide received, transferred and disposed of during the reporting period, plus the amount of each radionuclide “on hand” at the end of the reporting period. Alternate methods of reporting equivalent information may also be used. The activity of a radioactive source at any time can be determined from
where A(t) is the activity at time t, A0 is the initial activity, t is the elapsed time since initial activity, and T1/2 is the half-life of the radionuclide. Note that T1/2 and t must be in the same units.
Controls within facilities where radioactive materials are used or stored are established to minimize radiation exposure and radioactive contamination. High standards of cleanliness and good housekeeping, proper supervision, and well-instructed personnel are significant elements in the control of radiation exposures and radioactive contamination. The PI is responsible for seeing that these conditions are met on a day-to-day basis in their laboratory.
Eating and drinking are prohibited when working with radioactive material. Protective gloves are required when working with loose radioactive material (powder or liquid). Surveying (when appropriate) and washing hands is required after working with loose radioactive material. Handling radioactive material should not be done if there are significant breaks in the skin (cuts or abrasions) that would permit entry of radioactive material or hinder the effective decontamination by vigorous washing.
Each person working in the laboratory shall clean up their work area and apparatus, and properly dispose of or store any radioactive material. No person or object subject to radioactive contamination is to leave a laboratory without being monitored for radioactivity. Suitable monitoring techniques are required; such as, using a G-M survey meter or conducting wipe tests. Consult with RSO if specific instructions are needed as to the proper technique for radiation monitoring.
Tables and bench tops on which radioactive material is used shall be made of, or lined with, a nonporous and chemical resistant material. Such surfaces are to be covered with a disposable material such as absorbent plastic-backed paper. When working under conditions that a spill or incident would not be confined to a small area, the work shall be done over a tray, or other provisions should be made to minimize the extent of a contamination incident. The extent of work areas and storage places for radioactive material within a laboratory are to be kept to a minimum.
Radioactive material is to be stored as far as practical from other work areas and behind sufficient shielding (lead for gamma emitters, plastic for beta emitters), when needed, to minimize the exposure of personnel. The exposure level should at no time be greater than 2.0 mR/hr at the surface of the storage container (closed). If the PI is uncertain on how best to properly store radioactive material, he/she should contact the RSO.
Radiation warning signs bearing the standard radiation symbol and proper wording must be posted in areas subject to radiation hazards when required by state and federal regulations. Containers of radioactive materials must bear labels with the radiation symbol and words “Caution (or Danger) Radioactive Materials”, and list the radioisotope, the amount of activity, the activity date, the PI’s name and contact information. Additional information on or near the containers may be provided if it will help minimize radiation hazards. Posting of signs must be in compliance with Texas Regulations for Control of Radiation, 25TAC § 289.202(z)-(dd). For advice as to proper signs and posting in restricted areas, consult with RSO.
Radioactive material or waste is not to be discarded by regular means of disposal. Specific rules, regulations, and guidelines must be followed for the disposal of radioactive material or waste. Emphasis is placed on the segregation of different types of waste according to radionuclide, half-life, chemical form, physical form, or combinations thereof. All radioactive waste disposals must be reflected on the inventory. Please contact the RSO for the proper waste disposal procedures.
Equipment with the potential to emit radiation (i.e. x-ray unit) shall be dispositioned as active or inactive. The equipment shall be inventoried with status and documentation retained by the RSO. Requirements for radiation safety officers can be found in §289.226(t)(1) Registration of Radiation Machine Use and Services. Form: RC 42-3 RSO form.
What is the process for transferring a piece of equipment?
The registrant will need to submit a completed RC-18R Radiation Machine Transfer & Disposal form indicating disposition of equipment. The form must be signed and dated by the RSO.
What is the process for terminating a site?
The registrant will need to submit a letter requesting termination indicating which site(s) to terminate & disposition of equipment or complete the RC-18R Radiation Machine Transfer & Disposal form. The letter or form must be signed and dated by the RSO
What is the process for terminating a registration?
The registrant will need to submit a completed RC- 17-R Termination of a Certificate of Registration indicating disposition of equipment. The form must be signed and dated by the RSO.
The RSO or his designate will inspect all areas where radioactive materials are used or stored to ensure that safety requirements are being met. This will include following:
The RSO or his designate will regularly survey and/or wipe test any laboratories actively engaged in the use of radioactive material. More frequent wipes and/or surveys will be performed when:
Laboratory personnel shall perform additional surveys during procedures that could cause contamination or exposure concerns in addition to their routine in-process and post work surveys. The RSO should be contacted when any technical assistance is needed such as, during non-routine decontamination procedures.
Except for hoods and other enclosed areas not susceptible to the transfer of removable activity, Radiation Safety personnel will take action to have laboratory areas decontaminated if a wipe test exceeds 100 disintegrations per minute (dpm) beta/gamma or alpha activity averaged over 100 cm2.
Any contamination exceeding this limit will be highlighted on the lab map and delivered to the Principal Investigator as soon as practicable. Lab wipes that indicate levels of contamination 10 times the limit stated above are immediately made known to the Principal Investigator and the areas will wipe tested again by Radiation Safety personnel within seven working days. Radiation Safety personnel will provide technical assistance during any laboratory or personnel decontamination procedure, as necessary.
During laboratory surveys conducted by Radiation Safety personnel, any elevated radiation levels found that are not considered as low as reasonably achievable will be discussed with the PI and an attempt will be made to resolve the situation.
Any personnel performing a wipe test must wear disposable latex gloves. The wipe medium should consist of an absorbent paper measuring approximately 2.5 cm x 3.0 cm. All wipe papers should be moistened with ethanol just prior to being used. Each wipe should represent a surface area as close to 100 cm2 as possible, but typically should be made in a random pattern over the general areas of interest.
The Radiation Safety Officer or authorized delegate will oversee the surveying of the areas where the radioactive materials are stored and/or used, and provide the following technical support as needed:
The University is committed to the concept of personnel radiation exposures being as low as reasonably achievable (ALARA) and the following guidelines shall be observed:
The radiation dose to minors and an embryo/fetus shall not exceed 10 percent of the limits stated below. The radiation dose to all other radiation workers shall not exceed an annual total effective dose equivalent of: 5 rem (0.05 Sievert) to the body; orn15 rem (0.15 Sievert) to the eye; or 50 rem (0.5 Sievert) shallow dose to the skin or any extremity.
In keeping with the ALARA policy, the RSO recommends that doses to radiation workers be limited to 10 percent of the dose limits described above. Any monitored individual exceeding these quarterly dose limits will be notified by RSO so that they may be able to modify their techniques to reduce their radiation exposure.
Declared pregnant workers may be occupational radiation workers provided that they follow all applicable personnel monitoring and dose restrictions outlined above, and ensure that assigned whole body dosimeter is worn at waist level at all times while at work.
All operations involving the use of radiation shall be conducted in such a way to restrict the total effective dose equivalent to individual members of the public (non-radiation workers) as follows: 0.05 rem (0.5 millisievert) per year; or 2 mrem (0.02 millisievert) in any one hour.
All personnel entering areas where a whole-body personnel dosimeter has been deemed to be appropriate shall wear the device in the position that will likely indicate the highest whole body dose (e.g., between chest and waist level, outside of clothing).
At a minimum, individual radiation dosimeters shall be worn by:
Personnel working with radioactive materials that are issued an extremity dosimeter (ring TLD), shall wear the dosimeter on a finger with the sensitive portion of the dosimeter toward the palm of their hand; i.e., closest to the source of radiation, so that the finger does not shield the dosimeter from the radiation. Those working with other sources of radiation; e.g., x-ray diffraction units, shall wear the ring dosimeter with the sensitive portion on their finger facing the radiation source. Ring dosimeters shall be worn under gloves when necessary to prevent device contamination. Radiation workers issued any type of personnel monitoring device, extremity or whole-body, shall not allow the assigned device to be worn by any other person.
Radiation workers will be issued a ring dosimeter on the following basis:
In the event of an emergency involving radiation, special precautions must be taken to protect personnel. Items to be considered for use include coveralls, disposable gloves, disposable shoe covers, respirators, decontamination wash powder, radiation dosimeters, survey instruments, radiation signs, tags, labels, tongs, plastic bags, etc. Prompt notification to the RSO can expedite the arrival of needed equipment at the scene.
Requirements for the notification of incidents are located in 25TAC § 289.202(xx). Requirements for reporting exposures, radiation levels, and concentrations of radioactive material exceeding the limits are located in 25TAC § 289.202(yy).
During business hours (9:00 a.m. to 5:00 p.m. work days), call the Radiation Safety Officer. After working hours, weekends or holidays, call the St. Mary’s Police. Provide the following minimal information: your name; building and location; description of the accident; type of radioactive material to be used; and estimated severity of incident/injury.
Stay on the line until all necessary information has been provided. If you called St. Mary’s University Police, they will notify the RSO and the appropriate emergency response personnel.
After notifying the RSO/Safety Committee, the TDSHS, Radiation Control Program is required to be notified by telephone with confirmation within 24 hours of any incident involving any source of radiation, which may have caused or threatens to cause either of the following:
The release of radioactive material, inside or outside of a restricted area, so that, had an individual been present for 24 hours, the individual could have received an intake in excess of five (5) times the occupational annual limit on intake (ALI). This provision does not apply to locations where personnel are not normally stationed during routine operations, such as hot-cells or process enclosures.
Twenty-four hour notification to the TDSHS, Radiation Control Program is required initially with confirmation within 24 hours of any incident involving any source of radiation, which may have caused or threatens to cause:
The release of radioactive material, inside or outside of a restricted area, so that, had an individual been present for 24 hours, the individual could have received an intake in excess of one (1) occupational annual limit on intake (ALI). This provision does not apply to locations where personnel are not normally stationed during routine operations, such as hot-cells or process enclosures. In the event of a radiation incident, the procedures outlined in the following section shall be followed immediately.
Radioactivity cannot be destroyed by chemical or physical means. Decontamination, therefore, must depend upon the removal of the radioactive material. Removal of contaminants falls into two general methods, physical or chemical removal. It can be further divided into the removal from personnel and from materials or areas.
Any area is considered contaminated if removable activity is at a level greater than 1000 disintegrations per minute (beta, gamma) per 100 cm2. Every effort should be made to prevent the spread of contamination during decontamination.
When liquid radioactive material is spilled, specific action must be taken. Listed below, in order of priority, are steps to be taken in handling a spill of this nature:
Decontamination of any workers involved in a major incident must be performed under the supervision of Radiation Safety personnel, if possible. Skin should be decontaminated immediately and contaminated clothing should be promptly removed. Skin and clothing contamination shall be reported to the Radiation Safety Officer so a determination can be made if the quantities exceed one-tenth of the quantities listed in TRCR, 25TAC § 289.202(f)(1).
Decontamination of the area should begin as soon as possible, but after personal injuries are taken care of. Because St. Mary’s does not currently have staff trained in decontamination, the affected area should be cordoned off for restricted access, and a qualified contractor should be contacted as soon as possible for cleanup, decontamination, and subsequent monitoring.
If a person is both injured and contaminated, a quick decision will have to be made as to the best possible course to follow. An appropriate course of action should be:
Radiation Safety personnel will evaluate the extent of all potential personnel exposures. If necessary, arrangements will be made for the exposed person to go to an appropriate facility for examination to determine the extent of any radiation dose and/or treatment.
In determining the severity of the injury contamination, the following factors must be considered:
All cuts that penetrate the skin offer a point of easy access to the body for radioactive materials. Radioactive material should not be allowed to contact a cut anywhere on the body. If a contaminated article cuts a person, the wound should receive immediate treatment. It should first be cleansed very thoroughly with soap and water. Free bleeding should then be checked for contamination if a high-energy beta or gamma emitter is known to be involved. Soft beta and gamma emitters cannot be easily detected in a cut, particularly in the presence of water. All cuts involving possible contamination should be reported to the RSO so that necessary steps can be taken immediately to evaluate the contamination.
Instructions: The Principal Investigator (PI) must complete this document and forward it his/her Department Chairperson for approval. Once the Department Chairperson approves this proposal, the chairperson shall send it to the University Radiation Safety Officer. The Radiation Safety Officer will review this proposal and then present it for approval to the St. Mary’s University Safety Committee. This proposal must be approved by the RSO and the University Safety Committee prior to initial use of radioactive material on campus.
Instructions: Each Principal Investigator that uses radioactive material (licensed and exempt) is required to keep an inventory of radioactive materials in their possession. Inventory reports should be submitted annually to the RSO at the beginning of the fiscal year (June 1). The activity of a radioactive source at any time can be determined from where A(t) is the activity at time t, A0 is the initial activity, t is the elapsed time since initial activity, and T1/2 is the half-life of the radionuclide. Note that T1/2 and t must be in the same units.