Radiation Safety Manual

Transcription

1 2014 Radiation Safety Manual

2 To ensure that all information is the most up-to-date, no forms or SOPs are included in this manual but rather a link to their location on the IRM website is provided from which they can be directly filled-out and/or downloaded RYERSON UNIVERSITY Radiation Safety Manual Rev Page 2 of 50

3 TABLE OF CONTENTS TABLE OF CONTENTS... 3 LIST OF TABLES... 6 LIST OF FIGURES ADMINISTRATION AND RESPONSIBILITY Scope Authority and Responsibility Legislation and Guidance Documents Stakeholder feedback mechanisms Radiation Safety Officer Department Chairs Permit Holders Individuals Working with Radionuclides SETTING UP A LABORATORY FOR UNSEALED RADIOACTIVE MATERIALS Top 5 Requirements Approval and Design of Radionuclide Laboratory Locations Ryerson Radiation Permit Requirements Projects involving more than Exemption Quantities of a radionuclide Occupational Exposure Monitoring Personal Dosimetry Permissible Doses Internal Contamination Bioassay Requirements Selection of Radiation Detection Equipment Dose Rate Monitoring (External Radiation Levels) Contamination Monitoring (Amount of Radioactive Material) Training Requirements STANDARD OPERATING PROCEDURES FOR LABORATORY WORK ALARA Personal Protective Equipment Laboratory Coats Gloves Safety Glasses/Goggles or Face Shields RYERSON UNIVERSITY Radiation Safety Manual Rev Page 3 of 50

4 Footwear General Requirements for Work Area Safety Exposure Monitoring Action Levels Bioassay Requirements Posting of Required Laboratory Signs Purchasing Radioactive Materials Procedures for Ordering Radioactive Materials Transfer of Radioactive Materials Transfers within the University Transfers from Outside Institutions Receipt of Radioactive Packages Inventory Control Storage Waste Disposal General Specific Radioactive Waste Streams Aqueous Washes Radiation Detection Equipment Choice of Instrument Efficiency Annual Calibration Registration Maintenance Radiation Surveys for External Radiation and Contamination Dose Rate Surveys Detection of Surface Contamination Record Keeping Requirements Inventory Records Contamination Monitoring Waste Records Training Records RYERSON UNIVERSITY Radiation Safety Manual Rev Page 4 of 50

5 Inspection Records Sealed Source records Calibration Records Work Practices for Specific Radionuclides Low Energy Beta Emitters High Energy Beta Emitters Gamma Emitters Sealed Sources Leak testing for sealed sources of 50 MBq (1.35 mci) or more Decommissioning Rooms Ryerson Radiation Permit Revisions Amendments Renewals Sabbatical/Extended Leave Inactive Status Suspension/Revocation Expiry/Termination Self-Audit Checklist Top 10 Things to Remember SECURITY Authorized Access Maintaining Security Bringing Radioactive materials on Campus Missing Radioactive materials EMERGENCY PROCEDURES REFERENCES Regulatory Agencies Professional Radiation Safety Associations APPENDIX A RYERSON UNIVERSITY Radiation Safety Manual Rev Page 5 of 50

6 LIST OF TABLES Table 1. Classification of Basic and Intermediate Rooms for Various Isotopes Table 2. Radiation Exposure - Annual Limits Table 3. Action Levels for Individual Doses Table 4. Action Levels for Bioassay Monitoring Table 5. Requirements for Laboratory Signs Table 6. Exemption quantities for selected radionuclides Table 7. Radioactive Waste Disposal Criteria for Individual Radioisotopes Table 8. Action Levels for Removable Surface Contamination in Controlled Areas for Selected Radioactive materials Table 9. Decontamination Methods for Removable Surface Contamination Table 10. Classification of Selected Radioactive materials for Removable Surface Contamination Levels in Decommissioned or Public Areas Table 11. Classification of Minor Spills for Selected Radionuclides Table 12. Procedures for Decontamination of Contaminated Personnel LIST OF FIGURES Figure 1. Organization/Reporting Structure at Ryerson University... 9 Figure 2. Thermoluminescent dosimeter showing internal lithium fluoride chip Figure 3. Radioactive Warning Sign RYERSON UNIVERSITY Radiation Safety Manual Rev Page 6 of 50

7 1. ADMINISTRATION AND RESPONSIBILITY 1.1. Scope These procedures form part of the Radiation Safety Program and apply to all faculty, staff and students using, receiving, possessing, working and disposing open radioactive sources in all areas and facilities controlled by Ryerson University. The Canadian Nuclear Safety Commission issues Ryerson University a Consolidated Licence for all its radioactive materials. The license allows Ryerson University to possess, store and use specified radioactive materials. The Radiation Safety Program outlines the regulatory requirements in observance with this license and associated legislation Authority and Responsibility The University shall establish a Radiation Safety Program for ionizing radiation producing open sources in accordance with Canada s Nuclear Safety and Control Act and applicable regulations and regulatory documents, administered by the Canadian Nuclear Safety Commission. All occupational exposures to ionizing radiation shall be limited in accordance with the ALARA principle (As Low As Reasonably Achievable) and within legislated prescribed dose limits. Ryerson University s Radiation Safety Program is designed to keep exposures ALARA through training and implementation of standard operating procedures and protocols to control the storage, handling and disposal of radioactive materials. Responsibility for controlling all activities related to ionizing radiation safety at Ryerson University rests with the offices of the Provost and Vice President Administration and Finance. Their authority in this regard is received from the President of Ryerson University. Details of the enforcement policy are outlined in Appendix A Legislation and Guidance Documents All radioactive materials are regulated under the jurisdiction of various acts and regulations under the Canadian Nuclear Safety Commission (CNSC), including the Nuclear Safety Control Act, almost 75 regulations and guidance documents, and a Consolidated Licence issued by the CNSC to the University. The Consolidated Licence allows Ryerson University to purchase, possess, use, store and dispose of radioactive materials, provided all the conditions of the Licence are followed. This type of licence allows the University flexibility for managing its own radiation protection program. However, because it is a single licence, all actions impact on the licence's viability. In other words, if a serious event in one location were to occur, this single licence may be jeopardized which would affect work throughout the entire University. Copies of all relevant CNSC Acts, regulations, and guidance documents are available via the Radiation Safety Officer or through the department's website ( under the Radiation Safety Program. RYERSON UNIVERSITY Radiation Safety Manual Rev Page 7 of 50

8 1.4. Stakeholder feedback mechanisms In order to receive advice and direction on radiation safety matters, all stakeholders (permit holders, technical staff, and other parties involved such as Faculty, Deans/Directors implicated or specialized in radiation-related fields) are encouraged to provide feedback to the RSO who will collect and report back to the VP Administration and Finance and Provost. Every year, a report will go out to all permit holders, the VP Administration & Finance, and Provost. This reports is prepared by the RSO and will include the following statistics: Number of new permits Number of permit renewals/updates Number of individuals trained Inspection results List of licence amendments (if any) Updates to CNSC act or regulations List of stakeholders' comments/advice/requests and follow-up The current organizational structure for radiation safety at Ryerson University is shown in Figure 1 below. RYERSON UNIVERSITY Radiation Safety Manual Rev Page 8 of 50

9 Figure 1. Organization/Reporting Structure at Ryerson University President Vice President Administration & Finance Provost Vice President Research & Innovation Director Integrated Risk Management Deans Assistant Director Risk Management & Prevention Chairs & Academic Directors Radiation Safety Officer Permit Holders Users RYERSON UNIVERSITY Radiation Safety Manual Rev Page 9 of 50

10 1.5. Radiation Safety Officer Integrated Risk Management The position of Radiation Safety Officer receives its authority from the Vice President, Administration & Finance, through the Director, Integrated Risk Management and the Associate Director, Risk Management & Prevention of Ryerson University. The Radiation Safety Officer is responsible for coordinating all activities related to radiation safety, and for making recommendations to the Vice Presidents, through the Assistant Director, Risk Management & Prevention, regarding the control of all activities related to radiation safety. The Radiation Safety Officer is responsible for coordinating the daily activities of the Radiation Safety Program. Annual reports to the Canadian Nuclear Safety Commission will be prepared and submitted on behalf of the University by the Radiation Safety Officer. The RSO also has the duty to report, upon having been made aware of, any incident or situation defined in Section 29 of the General Nuclear Safety and Control Regulations and file a full report of the situation within 21 days, unless some other period is specified in the licence, and this report shall contain the following information: the date, time and location of becoming aware of the situation; a description of the situation and the circumstances; the probable cause of the situation; the effects on the environment, the health and safety of persons and the maintenance of security that have resulted or may result from the situation; the effective dose and equivalent dose of radiation received by any person as a result of the situation; and the actions that have been taken or proposed to be taken with respect to the situation Department Chairs For areas using radioactive material(s), each departmental chair is responsible for providing adequate facilities, equipment, instruments, supervision to control radiation hazards and to comply with the University s radiation protection requirements. And ensure that faculty, staff and students receive proper training Permit Holders Each individual who directs and supervises the use of unsealed radioactive materials is responsible for complying with the requirements outlined in the Canadian Nuclear Safety Commission, licences issued to the University, as well as with any additional requirements prescribed by internal procedures contained in the Radiation Safety Program. This individual will required to obtain an internal permit for the use of unsealed radioactive materials and will be deemed to be a Permit Holder. NOTE : Strict adherence to the conditions of approval for each and every internal permit is critical. Failure to comply will not only result in cancellation of individual permits but will seriously jeopardize the continuance of the University s Consolidated Licence. Each Permit Holder is responsible for: a) Following the conditions as stated in the permit and that safe laboratory practices as stated in the standard operating procedures as prescribed by the Radiation Safety Program. RYERSON UNIVERSITY Radiation Safety Manual Rev Page 10 of 50

11 b) Ensuring all staff using radioactive materials have been trained regarding the policies, procedures and programs on the safe use of radioactive materials at Ryerson University and are authorized to use radioactive materials. c) Ensuring that students using radioactive materials are properly supervised and ensuring they receive instruction in the safety procedures and University protocols on the safe handling of radioactive materials. d) Ensuring that all staff, students and researchers participate in required radiation safety training. e) Ensuring that designating work and storage areas for radioactive materials are maintained in proper working order, kept clean, properly labelled, are adequately shielded and that existing ventilation is not impaired. f) Ensuring that all staff working with radioactive materials have been issued, and wear a thermoluminescent dosimeter and participate in the bioassay program, as required. g) Ensuring that any radiation monitoring equipment used by the laboratory staff is adequate to the task and functioning properly. h) Allowing only authorized persons to enter rooms that are specified as restricted areas for reason of ionizing radiation protection. i) Maintaining an up to date inventory of all radiation sources (isolated sources or sources incorporated into equipment). This is to include a listing of the rooms in which radioactive materials are located or used. provides a standard inventory form (different form for Sealed Vs Unsealed sources). j) Reporting to the Radiation Safety Officer any incidents involving abnormal activities such as loss of materials, suspected exposures to ionizing radiation exceeding permissible standards. k) Ensuring that all radioactive materials are properly stored. l) Coordinating all purchases, acquisitions, transfers and disposal of radioactive materials, sealed sources and devices containing such sources with the Radiation Safety Officer, prior to any arrivals or movement off campus. m) Notifying the Radiation Safety Officer whenever the permit holder will be unavailable to supervise, identifying another permit holder who has accepted the responsibility as the temporary supervisor Individuals Working with Radionuclides All persons working with unsealed radioactive materials have certain responsibilities. These are: a) Working in compliance with all policies, procedures and requirements at the University using protective and/or monitoring equipment required for the safe use of radioactive materials. b) Reporting to the Permit Holder any defective equipment, violation or situation that may endanger a worker or create an unauthorized release of radioactive materials to the environment. c) Not creating or participating in any activity which may endanger themselves, any other worker or create the potential for unauthorized release of radioactive materials to the environment. RYERSON UNIVERSITY Radiation Safety Manual Rev Page 11 of 50

12 2. SETTING UP A LABORATORY FOR UNSEALED RADIOACTIVE MATERIALS 2.1. Top 5 Requirements Before any work is performed with unsealed radioactive materials, advance preparation is required to set up equipment, and implement regulatory and administration protocols. Here are the top five items that are required to be completed before the first isotope is purchased: 1. LAB DESIGN a) Approval of radioisotope laboratory design and classification of containment level 2. RADIATION PERMIT a) Submitting an application and receiving approval for a Ryerson Radiation Permit 3. EXPOSURE MONITORING a) Depending on the activity and type of isotope(s) used, occupational exposure monitoring for all lab personnel that will be working with radioisotopes may be required: i. For high energy beta emitters (e.g.p-32) and gamma emitters (e.g. Cr-51, I-125, I-131) an application for TLD badge must be submitted and a badge assigned and received from the Radiation Safety Officer ii. Where applicable, bioassays for radioiodines or low energy beta emitters such as H-3 may be required. 4. EQUIPMENT a) Radiation detection equipment is required to monitor surface contamination and in some cases external dose rate. 5. TRAINING a) Laboratory staff, from principal investigator to summer student, will not be allowed to use unsealed radioactive materials or order materials without appropriate training. Training will be mandatory prior to the issuing of any TLD badge. Training requirements may vary consult Radiation Safety Officer. b) Below is a more comprehensive explanation for each topic that expands on the requirements Approval and Design of Radionuclide Laboratory Locations All areas including laboratories, storage areas, counting rooms, etc, where the use of radioactive materials is proposed must be approved by the Radiation Safety Officer prior to radioactive materials being used or stored. All rooms intended to be used for the handling, storage or disposal of a radioactive material must conform to the requirements of Canadian Nuclear Safety Commission (CNSC) Regulatory Guide R52 (Rev 1) Design Guide for Basic and Intermediate Level Radioisotope Laboratories, or updated regulation : If a laboratory has not been previously approved, it will require an inspection by the Radiation Safety Officer before any use of radioactive materials is permitted in the laboratory. The Canadian Nuclear Safety Commission (CNSC) regulates the classification of rooms, based on the amounts of activity (and by isotope) in each room. A radioisotope laboratory is classified as Basic Level, Intermediate Level, High Level, or Containment Level. RYERSON UNIVERSITY Radiation Safety Manual Rev Page 12 of 50

13 Laboratory classification is based on the radioactive material to be handled in the laboratory. For Basic Level Rooms, the Radiation Safety Officer will authorize the area and designate the room. For proposed work in laboratories with activities greater than listed for a Basic-Level Room, the University requires written approval from the CNSC for every higher containment areas (i.e. Intermediate-Level Rooms or greater levels of containment). Table 1 outlines the classification of basic and intermediate rooms for a few of the most common radioisotopes. Table 1. Classification of Basic and Intermediate Rooms for Various Isotopes Isotope Exemption Quantity (MBq) ALI a (MBq) b Basic Level ( 5 ALI per container) MBq mci b Intermediate Level MBq (>5 & 50 ALI) C Cr , H , I P P S Source link: the nuclear substances and radiation devices licence application guide mci Notes: a) ALI ( Annual Limit on Intake) means the quantity, in Becquerels of a radionuclide which, when taken into the body, will deliver an effective dose of 20 msv over the 50 years following its intake. Only the most restrictive ALI is listed here (either Inhalation or Ingestion) b) 37 MBq = 1 mci If multiple radioisotopes are proposed to be used in the same location, then the proposed laboratory would be classified according to the most restrictive quantity. For example, if a researcher intends to use 150 MBq of Sulphur-35, 37 MBq of Tritium and 37 MBq of Carbon-14, the radioisotope laboratory would be required to be classified as an intermediate level laboratory due to the quantity of Sulphur- 35 present and will require written approval from the CNSC. No permit can be issued until this approval has been received. Depending on designation of the Level of Classification, CNSC lab posters will be required to be posted as well. These are available through the RSO, who must assign the lab classification based on the permit application/update information provided by the permit holder Ryerson Radiation Permit Requirements A Ryerson Radiation Permit issued by the University is required for any purchase, possession and use of radioactive material. A prospective user of open sources of radioisotopes must obtain an internal radioisotope permit before any radioactive material is brought onto the campus. This applies to all acquisitions of radioactive material, whether purchased, transferred, or donated. Apply on-line for a RYERSON UNIVERSITY Radiation Safety Manual Rev Page 13 of 50

14 permit at: or contact the Radiation Safety Officer if the system is not available for any reason. Applications for an internal RU Radiation Permit are reviewed and approved by the Radiation Safety Officer on behalf of the University. Permits are normally only issued to professorial or other approved staff having documented training and at least two years of experience in the use of radioisotopes. The term of the permit is at the discretion of the University, but cannot exceed the term of the CSNC issued Consolidated Licence. A copy of the most recent permit must be posted by the permit holder in each location listed on the permit. Radioactive material may not be used, stored, or disposed in a location not listed on the permit. Once a permit has been issued, there may be no changes to the facilities used, isotopes and quantities allowed without prior approval from the University. An internal permit does not normally cover off-campus use of radioactive materials. A special and separate approval will be required from the University Projects involving more than Exemption Quantities of a radionuclide In addition, written approval will be required from the Canadian Nuclear Safety Commission for any single use with more than 10,000 exemption quantities (EQ) of any radionuclide. In these cases, the actual research protocol must be approved by the CNSC. Refer to Table 1 for a listing of exemption quantities for common radionuclides. For radionuclides not listed in Table 1, please contact the Radiation Safety Officer Occupational Exposure Monitoring Personal Dosimetry Exposure monitoring with personal dosimeters monitors an individual s exposure history by recording the cumulative dose received from occupational exposure to high energy radiation sources. TLDs have a lithium fluoride chip which records the exposure to ionizing radiation. The badges are worn at chest or waist levels to record whole body exposure. Information obtained from exposure reports is useful to evaluate the effectiveness of protective measures and to prevent over-exposure. When working with a gamma or high energy beta emitter, a thermoluminescent dosimeter (TLD) badge is required to be worn. Depending on the proposed isotope and activity, a ring dosimeter may also be required to monitor extremity exposures. For example, P-32 users working with activities greater than 37 MBq, will be required to wear a ring dosimeter. Figure 2. Thermoluminescent dosimeter showing internal lithium fluoride chip All dosimetry is coordinated through the Radiation Safety Officer. The Radiation Safety Officer will determine the extent of dosimetry required. In order to receive a personal dosimeter, an application RYERSON UNIVERSITY Radiation Safety Manual Rev Page 14 of 50

15 form must be submitted to the Radiation Safety Officer for every individual planning to work with radioactive materials, prior to any work commencing. All information is considered confidential but is required to register new individuals with the National Dosimetry Services (NDS) in the Radiation Protection Branch of Health Canada. Badges are issued and processed by the National Dosimetry Services (NDS) where the records of exposure are maintained by the NDS. New badges to individuals are assigned and issued by the Radiation Safety Officer. A blank application form is available at All monitoring results are maintained and evaluated by the Radiation Safety Officer. Refer to Section 3.4 and under Standard Operating Procedures for the proper use and storage of TLD badges. TLDs are insensitive to weak beta emitters such as Tritium (H-3), Sulphur 35 (S-35) and Carbon 14 (C-14), and therefore TLD badges are ineffective. Refer to Section for monitoring for these isotopes Permissible Doses General Public The exposure from sources of ionizing radiation shall normally be controlled in such a way as to provide assurance that no individual or user shall receive an absorbed dose in excess of the values outlined by the CNSC and listed in Table 2. Table 2. Radiation Exposure - Annual Limits Member of the Public/ Non-NEW Nuclear Energy Worker (NEW) Annual (msv) Pregnant (msv) Annual (msv) Pregnant (msv) Whole Body Extremities (hands & feet) 4 over 9 months Lens of the Eye Skin Source: Nuclear Energy Workers a) Under the Nuclear Safety and Control Act, a Nuclear Energy Worker (NEW) means any person who in the course of his work, business or occupation, is likely to receive a dose of ionizing radiation in excess of the annual dose to the general public specified in Table 2. Each person who, in the opinion of the Radiation Safety Officer, may be exposed to external or internal radiation from sources (except prescribed medical treatment) in excess of the limits for a member of the public as listed in Table 2, will be classified as a Nuclear Energy Worker. Those individuals classified as a NEW will be required to sign an acknowledgement of their classification. RYERSON UNIVERSITY Radiation Safety Manual Rev Page 15 of 50

16 b) Any pregnant worker designated as a Nuclear Energy Worker must inform the Radiation Safety Officer, in writing, as soon as she is aware of her condition. The dose rate to a pregnant NEW may not exceed 0.25 msv over 2 weeks to a maximum of 4 msv for the period of her pregnancy Internal Contamination Bioassay Requirements Thermoluminescent dosimeters do not monitor exposure to low energy beta emission isotopes (e.g. H- 3, C-14). Workers using such isotopes may be required to participate in the bioassay program and submit biological samples for monitoring of radioisotopes. In addition, handling radioiodines such as Iodine 131 (I-131) and Iodine 125 (I-125) may require additional biological monitoring. Biological monitoring uses bioassay techniques to determine the amount of a particular radioisotope in the body. Two methods can be used for carrying out a bioassay technique - in vitro and in vivo. In vitro techniques are used when a small sample of a body fluid or tissue is sampled and analyzed in a detector. This is the technique used when urine is monitored for assessing tritium uptake. In vivo techniques involve measuring the amount of radioactive material by placing detectors close to the surface of the body. This technique is used for assessing the uptake of radioiodine in the thyroid. Refer to Section 3.4 for action limits for bioassay requirements. The Ryerson Radiation Permit will stipulate the conditions under which a bioassay is required. The frequency of the bioassay monitoring is dictated by the activity of the radioisotope. It is the responsibility of the Permit Holder to ensure that bioassay monitoring is carried out when required by the conditions outlined in the Ryerson Radiation Permit. Contact the Radiation Safety Officer to arrange for a bioassay measurement Selection of Radiation Detection Equipment Appropriate radiation detection equipment must be obtained by the Permit Holder and made available to laboratory staff working with radioactive materials. Depending on the isotope and activity proposed to be used in laboratory work, Permit Holders may be required to carry out two different radiation surveys for: 1. External radiation levels 2. Surface contamination The ability of various radiation detection instruments to detect radionuclides of interest will vary with the instrument and manufacturer. Instrument sensitivity for direct reading portable instruments must be capable of making reproducible measurements at the criteria limits. The Radiation Safety Officer shall be contacted for guidance on the selection of instruments Dose Rate Monitoring (External Radiation Levels) It is a requirement for researchers working with high energy beta emitters such as Phosphorus-32 (P-32) and gamma emitters such as Chromium-51, Iodine-125, etc, to be able to determine dose rates. Survey meters will be required to survey incoming packages and monitor radiation levels around the work space, storage and disposal areas for such isotopes. Detectors with ion chambers are very RYERSON UNIVERSITY Radiation Safety Manual Rev Page 16 of 50

17 efficient. Geiger Mueller (GM) counters can also be used. A GM counter can measure radiation at lower radiation levels and is less expensive than a survey meter with an ion chamber detector. It is a requirement of the CNSC to have dose rate survey meters calibrated annually. Contact the Radiation Safety Officer to make arrangements Contamination Monitoring (Amount of Radioactive Material) Monitoring for surface contamination from unsealed radioactive materials will be required by all Open Source Permit Holders. Radioactive contamination may be measured directly or indirectly. Direct measurements use portable radiation detection instruments to detect both fixed and removable surface contamination. Direct measurement may be used when background radiation levels are negligible and the detector has sufficient sensitivity. To monitor large areas, it is more convenient to use a direct reading instrument, if it is suitable for the isotope being surveyed (ask the RSO). Indirect measurement of contamination is used when portable instruments are not sensitive enough or when the radiation background is too high. Indirect methods can only be used to monitor removable contamination. The higher efficiency, low background and multiple sample counting makes them ideal for contamination survey work. The most effective means of monitoring for surface contamination is through the use of swipes and liquid scintillation counting. Swipe tests only detect removable contamination. Low energy beta emitters (e.g. H-3, C-14 and S-35) have a very low efficiency for portable survey meters, and are best detected through the scintillation counting method. All radioisotope laboratories, except those exclusively using tritium (H-3), will have available a functioning portable instrument for contamination. Most laboratories will use a meter with a pancaketype Geiger-Muller (GM) probe. These detectors are useful for detecting the spread of contamination but Geiger counters have poor detection efficiency for gamma emitters, weak beta emitters, and cannot detect tritium. For high energy gamma emitters, a thick (2 or 3 mm) sodium iodide detector is best and for low-energy gamma emitters such as I-125, a detector with a thin (1 or 2 mm) sodium iodide scintillation crystal must be used. For low energy beta emitters like C-14 and tritium, only indirect methods can be used, such as liquid scintillation counting. Liquid scintillation counting is also good for all radionuclides. Discuss with the RSO to find the best method of detection for your particular needs Training Requirements The CNSC requires that all persons working with radioactive material obtain training in the safe handling of radioactive material prior to beginning work with the radioactive material. This training must include information on the risks associated with exposure to ionizing radiation, the safe use, handling, storage and disposal of radioactive material. It is the responsibility of the permit holder to ensure that all personnel working with radioactive materials under the permit holder s permit receive the appropriate training and know the proper policies and procedures for the use of radioactive materials before beginning work. Permit Holders are responsible to supervise and document the hands-on laboratory training involving experimental procedures, techniques and equipment used in working with radioactive materials. RYERSON UNIVERSITY Radiation Safety Manual Rev Page 17 of 50

18 The Radiation Safety Officer may exempt a person from the requirement to complete the Radiation Safety Course offered by Integrated Risk Management if the individual can provide proof of successful completion of an equivalent course at another institution or facility. However, all persons must be familiar with the policies and procedures in force at Ryerson University and successfully complete an examination before starting any work with radioactive materials. Participants who have successfully completed the examination are designated as authorized users and allowed to work with radioactive materials without direct supervision. Summer students or other temporary employees are also required to be trained before beginning work with radioactive materials. However, they may not work with radioactive materials without direct supervision by someone who has successfully completed the regular training course and examination. Permit Holders will be required to participate in refresher training every five years and all other radioisotope users such as staff and students will be required to participate in refresher training within a period of three to five years. 3. STANDARD OPERATING PROCEDURES FOR LABORATORY WORK 3.1. ALARA It is the policy of the University to maintain all occupational exposures to ionizing radiation in accordance with the ALARA principle. ALARA is an acronym for As Low As Reasonably Achievable. This takes into account the regulatory dose limits, social and economic factors being taken into consideration to ensure that every possible effort is used to keep radiation exposures as far below the regulated dose limit as practical. All occupational exposures to ionizing radiation shall be limited in accordance with CNSC legislation and the ALARA principle Personal Protective Equipment Direct contact with unsealed radioactive materials must be avoided by the proper use of protective clothing. Disposable items must be placed into radioactive waste disposal containers immediately after use. As a minimum, this consists of: Laboratory Coats Laboratory coats will be worn fully buttoned and should not be worn outside the active laboratory working areas. Lab coats may not be worn into non laboratory areas such as any eating areas. Where possible, coat hooks should be installed near the exit door to encourage laboratory personnel to remove such clothing before leaving the laboratory Gloves Disposable, impervious gloves used for radioisotope work must be removed before leaving the laboratory or after use to prevent the spread of contamination to non radioactive areas (e.g., to telephones and refrigerator or freezer door handles). RYERSON UNIVERSITY Radiation Safety Manual Rev Page 18 of 50

19 Safety Glasses/Goggles or Face Shields Safety glasses/goggles are required for any work involving unsealed radioactive materials. It is recommended that contact lenses not be worn in a laboratory Footwear Open-toed shoes are not permitted when handling unsealed radioactive materials General Requirements for Work Area Safety a) There shall be no smoking, drinking, eating or storage of food or food containers in any fridge, freezer or other areas used to contain radioactive materials. b) All personnel are expected to practice ALARA in their work practices. Each Permit Holder must implement procedures designed to reduce exposures to radiation to ALARA. c) Prior to conducting a new procedure involving radioisotopes, a test run using non-radioactive material should be carried out to test the procedure. d) Use the minimum quantity necessary to satisfy the objective of the procedure. e) Where ever possible, the handling of radioactive materials shall be restricted to a one area of the laboratory (e.g. dedicated bench area). The work area must be covered with disposable absorbent materials (e.g. bench covering material), which must be immediately discarded if radioactive material has been spilled. Disposable absorbent material must be replaced on a regular basis. f) External exposures to radiation will be minimized through the appropriate use of shielding material, increasing the distance from the radioactive source and reducing the time spent working with the nuclear substance. g) Internal exposures are minimized by preventing INGESTION, INHALATION, and ABSORPTION through the skin, by implementing proper work safety procedures. h) All equipment and other items used during a radioisotope procedure must be labelled with appropriate radiation warning labels. i) Where feasible, this equipment should be stored in a separate area away from general laboratory use. Before being returned to general use, all equipment must be properly decontaminated. Warning labels must be removed when the item has been decontaminated. j) Where possible, only one sink should be used for the washing of contaminated glassware and equipment. This sink should be clearly labelled with radiation warning signs. Glassware designated for work with radioactive materials should be washed separately. k) When not in use, all containers containing radioactive solutions must be covered and labelled with radiation warning tape, the name of the radioisotope and activity. l) Never pipette radioactive solutions by mouth. A radioactive solution must never be poured from one container to another, but must be transferred carefully with a disposable pipette or tip. m) Radioactive solutions must be transported in such a way as to avoid the spread of radioactive contamination in the event of breakage (e.g. in an outer plastic beaker or tray lined with disposable absorbent liner). RYERSON UNIVERSITY Radiation Safety Manual Rev Page 19 of 50

20 n) Where work with unsealed radioactive materials will result in release of radioactive material through volatilization, dispersion of aerosols or splatter, the work will be carried out in a fume hood equipped with an alarming flow monitoring device. o) All radioisotope work areas must be monitored within seven days of usage. Records of monitoring and corrective actions must be maintained and available for inspection. Particular attention should be paid to the floor below the radioisotope work area. Hands and clothing should be monitored to ensure that no contamination has occurred. p) Any radiation detector should be kept away from the radioisotope handling areas to prevent accidental contamination. While materials such as plastic wrap may be used to prevent contamination of the monitor from routine handling, it must be considered that any material placed over the detector will reduce the efficiency of the unit and will no longer be adequate for contamination monitoring purposes. q) Upon completion of a radioisotope experiment, all materials must be properly labelled. All material and equipment used during the procedure must be safely stored or prepared for disposal. r) Materials used in radioisotope area will be easily decontaminated. Cloth or fabric covered chairs are not permitted in radioactive work area. s) All equipment or devices which are to be sent for repair or maintenance must be decontaminated before being released from the radioactive working area. t) Before leaving the laboratory, all persons must wash their hands thoroughly Exposure Monitoring Care should be taken that the dose recorded by the thermoluminescent dosimeter (TLD) badge and/or ring dosimeter is representative of the true dose to the individual to whom it is assigned. The dosimeter must not be left in an area where it could receive a radiation exposure when not worn by the individual (e.g. left near a radiation source). In addition, the lithium fluoride chips inside the TLD badge are sensitive to light and may produce false results if exposed to ultraviolet, fluorescent lights or sunlight. Always store your dosimeters in a dark area with a low radiation background. Care should be taken to maintain dosimeters away from contamination, since this may also result in a false positive reading. Refer to Procedures for TLD Badges at ies/radiation.html under Standard Operating Procedures Action Levels An action level is defined by the Radiation Protection Regulations under the Nuclear Safety and Control Act of Canada as a specific dose of radiation or other parameter that, if reached may indicate a loss of control of part of a licensee s radiation protection program and triggers a requirement for specific action to be taken. They are compared to the annual exposure limits to ionizing radiation are set by the Canadian Nuclear Safety Commission (CNSC). The primary goal of the action to be taken is to prevent a re-occurrence of the event. Action levels are part of Ryerson s overall radiation protection program. They are designed to alert Ryerson faculty, staff and students before regulatory exposure limits are reached. Table 3 outlines the action limits for individual doses to external radiation and the steps required in the event of an overexposure. Refer to Ryerson s Radiation Safety Procedures for Action Levels RYERSON UNIVERSITY Radiation Safety Manual Rev Page 20 of 50

21 ( under Standard Operating Procedures) for more details. Table 3. Action Levels for Individual Doses Investigation Level Quarterly Action Level Annually (msv) (msv) whole body extremities whole body extremities Member of Public/ Non-NEW Nuclear Energy Worker (NEW) In the event of exposure greater than action levels in Table 3, the Radiation Safety Officer will: a) Conduct an investigation to establish the cause for reaching the action level b) Identify and take action to restore the effectiveness of the radiation protection program c) Notify the Canadian Nuclear Safety Commission within period specified in licence. In the event of when the CNSC dose limit is exceeded, the Radiation Safety Officer will: a) Immediately notify the individual and the CNSC b) Require the affected individual to immediately leave the work that may add to the dose c) Conduct an investigation to establish an estimate of the dose and the cause for the exposure d) Within 21 days, report to the CNSC on the progress of the investigation Bioassay Requirements Thermoluminescent dosimeters do not monitor low energy beta emission isotopes (e.g. H-3, C-14, S- 35). Workers using such isotopes may be required to participate in the bioassay program (i.e. biological monitoring) and submit biological samples for monitoring the amount of a specific radioisotope in the body. In addition, laboratory workers handling radioiodines (e.g. Iodine 131 and Iodine 125) are also required to participate in the bioassay program. The frequency of the bioassay monitoring is dictated by the activity and the radionuclide. The Ryerson Radiation Permit will stipulate the conditions under which a bioassay is required. Two methods can be used for carrying out a bioassay technique - in vitro and in vivo. In vitro techniques are used when a small sample of a body fluid or tissue is sampled and analyzed in a detector. This is the technique used when urine is monitored for assessing tritium uptake. In vivo techniques involve measuring the amount of radioactive material by placing detectors close to the surface of the body. This technique is used for assessing the uptake of radioiodine in the thyroid. RYERSON UNIVERSITY Radiation Safety Manual Rev Page 21 of 50

22 It is the responsibility of the Permit Holder to ensure that bioassay monitoring is carried out when required by the conditions outlined in the Ryerson Radiation Permit. Contact the Radiation Safety Officer to arrange for a bioassay measurement. Table 4. Action Levels for Bioassay Monitoring Isotope Bioassay Monitoring Frequency Investigation Level Action Level > 5 MBq (0.13 mci) in single use on open bench Iodine I-125 & I-131 OR spill > 5 MBq of volatile radioiodine in room >50 MBq (1.3 mci) in fume hood >500 MBq (13 mci) in glove box external contamination is detected on the person 24 hours after use & no later than 4 days after use 1 kbq (thyroid) 10 kbq (thyroid) process where significant intake is possible dependent on nature of H-3 (e.g., tritiated water vs. compounds, etc), method of handling (open bench or fumehood) and quantities Tritium (H-3) 100 kbq/litre (urine) 1 MBq/litre (urine) In the event of exposure greater than action levels in Table 4, the Radiation Safety Officer will: a) conduct an investigation to establish the cause for reaching the action level b) identify and take action to restore the effectiveness of the radiation protection program c) notify the Canadian Nuclear Safety Commission within specified period of licence. In the event of when the CNSC dose limit is exceeded, the Radiation Safety Officer will: a) immediately notify the individual and the CNSC b) require the affected individual to immediately leave the work that may add to the dose c) conduct an investigation to establish an estimate of the dose and the cause for the exposure d) within 21 days, report to the CNSC on the progress of the investigation Posting of Required Laboratory Signs After receiving a Radiation Permit and work begins with radioactive materials, the rooms where radioactive materials will be used or stored will require a variety of signage (Summarized in Table 5 below). Frivolous posting of radiation warning signs or labels is prohibited under federal legislation. a) Internal Permits are required to be posted in a visible location inside all locations listed on permit. The current staff list must be posted with the permit in the main laboratory of the permit holder. RYERSON UNIVERSITY Radiation Safety Manual Rev Page 22 of 50

23 b) A copy of the CNSC Rules for Working with Radioisotopes in a Basic/Intermediate/High Level Laboratory or updated information must be posted in each room where radioactive material is handled. Copies may be obtained from the Radiation Safety Officer. c) Entrances to areas where the effective dose rate is greater than 25 µsv/h (or 2.5 mr/hr) or the radioactive substance is in a quantity greater than 100 times its exemption quantity (as outlined in Table 6 below) in the room/area must be marked with a sign (shown in Figure 3) that has a radiation warning symbol and the words Rayonnement- Danger - Radiation. Signs can be obtained from the Radiation Safety Officer. RYERSON UNIVERSITY Radiation Safety Manual Rev Page 23 of 50

24 Rayonnement - Danger - Radiation Figure 3. Radioactive Warning Sign d) Equipment with more than one (1) exemption quantity (EQ) must have a label with a radiation warning symbol and the words Rayonnement- Danger - Radiation. The name, quantity, date of measurement and form of the radioactive substance in the container or device. Refer to Table 6 for some exemption quantities. A more detailed list is available from the Radiation Safety Officer. Table 5. Requirements for Laboratory Signs Location Entrance to: laboratory, storage area, or other permitted area with more than 100 EQs Information and Type of Posting Radioactive Warning Sign with Permit Holder name and office phone #, 24 hour contact number Radiation Safety Officer phone # Copy of the Internal Permit Inside the lab, in a prominent location Current list of authorized users (inside main lab only) CNSC Safety poster for appropriate Lab category Storage Location Radioactive Warning Sign Indicate dose rate if > 2.5 µsv/h at contact Work Area Radioactive Warning tape identifying work area RYERSON UNIVERSITY Radiation Safety Manual Rev Page 24 of 50

25 Table 6. Exemption quantities for selected radionuclides Radionuclide Exemption Quantity (Bq) Exemption Quantity (µci) Americium x Carbon-14 1 x Cesium x Cobalt-60 1 x Nickel-63 1 x Phosphorus-32 1 x Phosphorus-33 1 x Sulphur-35 1 x Tritium (H-3) 1 x Exemption quantities for other radionuclides may be obtained from the Radiation Safety Officer * Based on SCHEDULE I of the Nuclear Substances & Devices Regulations which is available online (most current): Purchasing Radioactive Materials The Canadian Nuclear Safety Commission (CNSC) requires that the University maintain a record of all radioactive materials received under the Consolidated Licence. This information is reported to the CNSC annually and must be available for inspection by the CNSC on demand. Therefore acquisition protocols for radioactive materials have been developed and must be strictly observed: Procedures for Ordering Radioactive Materials Orders can only be placed by permit holders or authorized staff to the Radiation Safety Officer. The Radiation Safety Officer will place the order with the company and charge back the researcher's cost centre. All orders must go through the Radiation Safety Officer. The Radiation Safety Officer must also approve any acquisitions (gifts, free samples, donations, loans, external transfers, exchanges, etc.) of radioactive materials, including sealed sources in devices, before shipment/transfer to the university. The following information will be required for the approval: permit Holder Name and permit number radionuclide activity per unit number of units supplier date expected delivery location (Building and room number) Any acquisitions which do not meet the criteria for approval will have to be corrected by the person reporting the acquisition. Failure to provide the necessary information will delay the approval. Any radioactive material arriving at the University for which there is no prior approval may be confiscated. RYERSON UNIVERSITY Radiation Safety Manual Rev Page 25 of 50