Radiation Safety Inspection and Audit Policies
The RSS performs routine inspections of each AU on campus. Inspections are often performed by EHS technicians and are designed to ensure that general radiation safety program requirements are being properly implemented within the laboratory. The inspection frequency is set based on the assessed risk of the authorization. Risk is assessed based on several factors. These include activity on hand, types of isotopes used, and inspection compliance history. Items covered in inspections may include:
- Documentation review (inventory records, swipe and survey records, etc)
- Postings and labels
- Instrumentation calibrated and functioning
- Implementation of ALARA and good lab practices
- Security of RAM
- Radiation Worker training
- Storage and handling of waste
- Previous inspection deficiencies and corrective actions
If an AU fails to correct an inspection deficiency by the time of the next inspection, this will result in a repeat violation. In the event that the same problems appear inspection after inspection, or disappear for a while and then periodically reoccur, a more aggressive approach will be taken to determine the cause of the problem(s), rectify the situation, and take measures to ensure that these deficiencies do not continue to occur. In these instances, the RSC will review the RAM authorization, including the inspection history, and evaluate if there is a need for termination of the authorization.
If the RSC determines that an authorization should be terminated based on the inspection results, the AU may petition to appear before the RSC to make a case for remaining active. At this time, additional restrictions may be placed on the AU in order for the authorization to remain active
Unlike radiation safety inspections, which focus on the implementation of the Radiation Safety Program requirements in a laboratory setting, an Audit of the authorization is an in-depth review of the AU's compliance history with the Radiation Safety Program, MU's NRC license conditions, and regulations. These audits are performed at least once a year, but may be performed more frequently at the discretion of the assigned Health Physicist. Based on the findings of the document review, the assigned Health Physicist may deem it necessary to perform an in-person review of the authorization as well. However, audits typically do not require lab visits from the Health Physicist.
Items for review during audits may include:
- Compliance with applicable DOT and/or NRC regulations (i.e. Medical Authorized Users must comply with 10 CFR 35 regulations)
- Records of radioactive materials receipt, use, and disposal including waste pickups and transfers
- Training records
- Documentation of periodic surveys including swipes, meter surveys, and any decontamination efforts performed for contaminated areas
- Inspection history including proper implementation of corrective actions in a timely manner and deficiency response in EHSA
- Frequency of RAM use (see RSC Policy #1 for long-term storage and non-use of RAM)
- Authorization specific SOPs including special conditions
- Semi-annual inventory verification
If the assigned Health Physicist observes significant issues with compliance, such as failure to implement corrective actions or repeat violations, the audit findings will be reviewed by the RSO and/or RSC to assess a need for termination, additional corrective actions, or authorization restrictions. Prior to finalizing the decision to terminate the authorization by the RSO and/or RSC, the AU's supervisor and RSC Representative (RSCR) will be notified of the situation, receive a copy of the audit results, and allowed time to provide input on final recommendations.
If the RSC determines that an authorization should be terminated based on the audit results, the AU may petition to appear before the RSC to make a case for remaining active. At this time, additional restrictions may be placed on the AU in order for the authorization to remain active.
An AU will rarely receive a deficiency for timely self-reported findings. The RSC intends there to be a self-reporting infrastructure so that a healthy ‘radiation safety culture’ will prevail.
The RSO is bound to maintaining a safe environment and is authorized to seize radionuclides and/or stop work that involves RAM in order to place an authorization in a safe condition in the event the AU cannot. These roles and responsibilities of the RSO are identified in the University's NRC license. The RSC will work in concert with the RSO to resolve any such issues.
Any items identified during inspections/audits or items identified outside of these time periods in which there is a clear lack of control of material or other serious violation, the RSO has the ability to temporarily inactivate the authorization until the situation comes under control and the AU appears before the RSC. The potential health and safety and regulatory implications will govern the remedial actions required. If the AU's authorization is immediately suspended, reactivation of the authorization will not occur until an RSC review has been conducted. The AU will be required, at a minimum, to report to the RSC what occurred, why it occurred, and how the AU intends to prevent a recurrence and ensure safe continuation of the authorization. Any documentation developed by the AU and personnel involved, or by the RSS and RSO, will be completed in a time frame compatible with NRC reporting requirements. Informational copies will be provided to the AU's Administrator.
Responding to Corrective Actions
When a deficiency is issued, the AU should conduct a complete and thorough review of the circumstances that led to the deficiency. The review should include: interviewing the personnel involved, reviewing relevant procedures for completeness or need for revisions, reviewing the training of those involved to see if a lack of training may have contributed to the problem, identifying the root cause of the deficiency, identifying the direct and indirect causes which may have led to the problem.
All deficiency responses must be entered into EHSA within 2 weeks (10 working days) of initial notification. Failure to respond to deficiencies may be reflected in the audit results. Deficiency responses may include immediate corrective actions. However, if the deficiency cannot be corrected immediately, the deficiency response should include why it cannot be corrected immediately and future corrective actions to resolve the matter in a timely manner.
Page last updated on August 19, 2021.