Radiation Safety Inspection and Audit Policies

Inspections

The Radiation Safety Staff (RSS) performs routine inspections of each PI on campus. These inspections may be announced or unannounced and are designed to ensure that general radiation safety program requirements are being properly implemented. The inspection frequency is determined by a risk assessment of the RAM permit. Risk is assessed based on several factors. These include activity on hand, types of radionuclides used and inspection compliance history. Items covered in inspections may include:

  • Documentation review (inventory records, swipe and survey records, etc.)
  • Postings and labels
  • Calibration and functionality of instrumentation
  • Implementation of ALARA principles
  • Security of RAM
  • Radiation Worker training
  • Storage and handling of waste
  • Previous inspection deficiencies and corrective actions

If a PI 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 Radiation Safety Committee (RSC) will review the RAM permit, including the inspection history, and evaluate if there is a need for termination of the permit.

If the RSC determines that a RAM permit should be terminated based on the inspection results, the PI may petition to appear before the RSC to make a case for remaining active. At this time, additional restrictions may be placed on the PI in order for the RAM permit to remain active.

Audits

Unlike radiation safety inspections, which focus on the implementation of Radiation Safety Program requirements in the workplace, an audit of the RAM permit is an in-depth review of the PI'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 (HP). Based on the findings of the document review, the assigned Health Physicist may deem it necessary to perform an in-person review of the RAM permit 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)
  • Permit specific SOPs including special conditions
  • Semi-annual inventory verification

If the assigned HP observes significant issues with compliance, such as repeat violations or failure to implement corrective actions, the audit findings will be reviewed by the RSO and/or RSC to assess the need for termination, additional corrective actions, or restrictions. Prior to finalizing the decision to terminate the RAM permit by the RSO and/or RSC, the PI'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 a RAM permit should be terminated based on the audit results, the PI may petition to appear before the RSC to make a case for remaining active. At this time, additional restrictions may be placed on the PI in order for the permit to remain active. 

Deficiency Follow-Up

A PI 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 tasked with maintaining a safe environment and is authorized to seize radionuclides and/or stop work that involves RAM in order to place a permit in a safe condition in the event the PI cannot. These roles and responsibilities of the RSO are identified in the University's NRC license. The RSC will work in conjunction 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 permit until the situation is resolved and the PI appears before the RSC. The potential health and safety and regulatory implications will govern the remedial actions required. If the PI's permit is immediately suspended, reactivation of the permit will not occur until an RSC review has been conducted. The PI will be required, at a minimum, to report to the RSC what occurred, why it occurred, and how the PI intends to prevent a recurrence and ensure safe continuation of the permit. Any documentation developed by the PI 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 PI's administrator. 

Responding to Corrective Actions

When a deficiency is issued, the PI 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, and 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 December 14, 2023.