Contents
1.1 Radiation Safety Committee
The Radiation Safety Committee (RSC) consists of the following: the Radiation Safety Officer (RSO), Vice President and Chief Campus Facilities Officer, and staff representatives from laboratories and departments using radioactive material or radiation sources. Prospective members of the RSC are approved by NYSDOH as required in 10 NYCRR Part 16 prior to confirmation.
Responsibilities
The Committee is responsible for:
- Ensuring individuals who work with or who may receive a workplace exposure to ionizing radiation have sufficient training and/or experience to enable them to perform their duties safely and in accordance with NYSDOH regulations and the conditions of the University’s License.
- Ensuring that all use of radioactive materials and radiation-producing equipment is conducted in a safe manner and in accordance with NYSDOH regulations and the conditions of the License.
Duties
The Committee shall:
- Be familiar with New York State regulations (10 NYCRR Part 16, 6 NYCRR Parts 380 and 381), the terms of the University’s radioactive materials License and any information submitted in support of request for the License and its amendments.
- Review the training and experience of individuals who use radioactive materials or radiation-producing equipment and determine that their qualifications are sufficient to enable them to perform their duties safely and in accordance with applicable regulations and the conditions of the License.
- Review and approve requests for use of radioactive materials and radiation-producing equipment within the University.
- Be responsible for monitoring the University’s program to maintain individual and collective doses as low as reasonably achievable.
- Establish a table of investigational levels for occupational radiation exposure, which when exceeded, will initiate an investigation and consideration of action by the RSO.
- Review semi‑annually, with the assistance of the RSO, occupational radiation exposure records of monitored personnel.
- Establish a program to provide individuals whose duties may require them to work in the vicinity of radioactive material or radiation producing equipment (i.e. security and housekeeping personnel) with proper instruction as required by Section 16.13 of 10 NYCRR Part 16.
- Prescribe special conditions that will be required during a proposed use of radioactive material such as requirements for bioassays, physical examinations of users, special monitoring procedures, etc.
- Review the Radiation Protection Program at least annually to determine that activities are being conducted safely and in accordance with NYS regulations and the conditions of the License. The review shall include an examination of records, reports from the RSO, results of NYS inspections, written safety procedures and the adequacy of the University’s management control system.
- Recommend remedial action to correct any deficiencies identified in the Radiation Protection Program.
- Maintain written records of Committee meetings, actions, decisions, and recommendations.
- Ensure the radioactive materials license is amended, when necessary, prior to any changes in facilities, equipment, policies, procedures, personnel, radioactive material and possession limits, as specified in the License.
- Be responsible for monitoring the University’s program to maintain releases of radioactive materials to the environment as low as reasonable achievable and in accordance with 6 NYCRR Part 380.
Meetings
- The Radiation Safety Committee shall meet as often as necessary to conduct its business, but not less than once in each calendar year.
- A quorum shall consist of at least one‑half of the Committee’s membership, including the RSO and the Vice President and Chief Campus Facilities Officer.
- All issues requiring Committee action, with the exception of applications for use of radiation sources, will be approved or disapproved based on the majority opinion of all members of the Committee. Applications for use of radiation sources will be approved or disapproved based on the majority opinion of the technical members of the Committee only.
1.2 Radiation Safety Officer
The University’s Radiation Safety Officer (RSO) receives his/her authority from the Radiation Safety Committee (RSC). The RSO is authorized to initiate remedial action or to temporarily halt or immediately terminate a project that is found to be a threat to health, safety or property or otherwise in violation of Federal, State or local regulations.
Responsibilities include:
- Coordinating the Radiation Safety Committee (RSC) review of the safety evaluations of proposed uses of radioactive material and radiation-producing equipment.
- Overseeing activities involving radioactive material and radiation-producing equipment including monitoring users through routine lab inspections performed at least twice per year and special surveys conducted at the request of the RSC or at the discretion of the RSO.
- Determining compliance with rules and regulations, License conditions and the conditions of project approval as specified by the RSC.
- Overseeing the receiving, opening and delivering of all shipments of radioactive material arriving at the University.
- Assuring that University guidelines and applicable regulations are adhered to in the shipping of all radioactive material leaving the University.
- Maintaining an inventory of radionuclides at the University and limiting when necessary, the quantities of radionuclides to the amounts authorized by the Licensee.
- Supervising, coordinating and maintaining accurate recordkeeping of the radioactive waste storage and disposal program.
- Directing the proper storage of radioactive materials.
- Distributing personnel monitoring devices and arranging for their processing.
- Determining the need for and evaluating bioassays and keeping records of personnel exposures.
- Performing or arranging for calibration of radiation safety‑related instruments.
- Assuring the performance of leak tests on sealed sources.
- Conducting training programs and instruction of personnel in the rules, guidelines, and regulations regarding the use of radioactive materials and radiation-producing equipment.
- Consulting on aspects of radiation safety to personnel at all levels of responsibility, including laboratory design, shielding and other radiation exposure controls.
- Supervising decontamination when necessary and appropriate.
- Maintaining appropriate records.
- Assuring that efforts are made to maintain discharges of radioactive materials to the environment as low as reasonably achievable and monitoring these releases as applicable.
- Reviewing the quality control activities performed with regard to the University’s Diagnostic X-ray Quality Assurance Program.
- Investigating personnel exposures in excess of the investigational limits established by the RSC.
1.3 Radiation Supervisors
All operations involving the use of radioactive materials or radiation-producing equipment at Syracuse University must be carried out under the direction of a Radioactive Materials Supervisor (RMS) or a Radiation Equipment Supervisor (RES), respectively. Designation as a RMS or RES is granted by the Radiation Safety Committee (RSC) to individuals who demonstrate that they are sufficiently knowledgeable of radiation protection principles, related compliance issues, proper procedures for the safe use of radiation and associated hazards.
The responsibilities of a Radiation Supervisor include, but are not limited to:
- Providing adequate facilities, equipment, instruments, supervision and instructions to control radiation hazards and to comply with the requirements of this Handbook and/or the RSC.
- Submitting requests for approval of all procedures involving the use of ionizing radiation to the RSC. This is accomplished by completing and submitting an “Application For Use of Radiation”.
- Maintaining with the RSO an up‑to‑date listing of areas in which ionizing radiation is stored, used or handled.
- Maintaining with the RSO an up‑to‑date listing of the names of individuals who may be handling radioactive material or operating radiation-producing equipment, or who may be occupationally exposed to ionizing radiation in his/her laboratory.
- Keeping an inventory of the quantity of radioactive materials and/or the type of radiation-producing equipment possessed.
- Keeping records of disposal of all radioactive material.
- Making periodic radiation surveys of each area in which ionizing radiation is used as required by the RSC.
- Controlling the entry to rooms which are specified as controlled areas, for reasons of radiation protection.
- Informing the RSO of changes in existing work which may increase the radiation exposure or the potential for radiation exposure.
- Providing security against unauthorized removal or use of radioactive materials and/or radiation-producing equipment.
- Ensuring that radiation workers under their supervision wear radiation exposure monitors during periods of possible exposure and that these monitors are stored in an appropriate location.
- Ensuring that radiation workers under their supervision are properly instructed and that this instruction is documented prior to performing any procedure which may involve possible exposure to ionizing radiation.
- Ensuring that all ionizing radiation procedures are conducted in a manner consistent with the University’s policy of maintaining exposures as low as reasonably achievable.
- Properly storing, handling, labeling and tracking radioactive wastes generated and stored in their laboratory and emphasizing the importance of waste minimization.
- Responding within the specified time frame to all requests for remediation or corrective action.
- Providing, in writing to the RSO, 60 days advanced notice of the intent to vacate a controlled area.
- Ensuring that only approved procedures involving the use of radioactive materials or radiation-producing equipment are performed and that these procedures conform to the terms of his/her “Application for Use”, State and Federal regulations and this Handbook.
- Notifying Radiation Safety Staff prior to the performance of procedure(s) which could result in a release of radioactive material to the environment.
- Ensuring that all exposures to radiation sources for which the Supervisor is responsible, are maintained within or below regulatory limits.
1.4 Radiation Workers
Radiation workers are individuals authorized by the RSO to work with radioactive materials or operate radiation-producing equipment. An individual must obtain Radiation Worker status prior to independently performing any procedure involving ionizing radiation. Radiation workers are required to have a basic understanding of radiation protection practices and the hazards associated with the use of ionizing radiation.Each must act in accordance with the guidelines established in this Handbook, rules established by the RSC and their supervisor and all applicable laws and regulations. Workers must also make every effort to maintain their exposure to ionizing radiation as low as reasonably achievable. An overview of the University’s Radiation Worker training requirements are provided in Section 1.6 of this Handbook
1.5 Non-Radiation Workers Required to Enter or Work in Radiation Use Areas
(i) “Non-Radiation Use” Laboratory Employees
Laboratory employees who will not actively handle radiation sources (i.e. open sources of radioactive material, sealed radioactive sources or x-ray equipment) but may perform assigned duties in or in the immediate vicinity of a controlled radiation area(s) must be informed of the radiation hazard present. The extent of training the individual must receive depends on the nature of the hazard present in the laboratory, the duties the individual will perform and the anticipated radiation dose to the “non-radiation use” employee. This individual’s radiation related duties must be clearly defined and submitted to the RSO for determination of the extent of training the individual must receive prior to performing the duties. Radiation exposure monitoring may be provided to an occupationally exposed, “non-radiation use” laboratory employee at the discretion of the RSO based on the exposure potential present in the laboratory and/or the individual’s assigned duties.
Upon completion of the required training, “non-radiation use” laboratory employees may only access controlled radiation areas to perform those duties specifically approved by the RSO. At all other times, these employees must not enter or work in controlled radiation areas to help ensure that their exposures are as low as reasonably achievable.
Information regarding the training required for “non-radiation use” laboratory employees prior to entry into controlled radiation areas is provided in Section 1.6.4 of this Handbook.
(ii) “Non-Radiation User” Non-Laboratory Employees
Non-laboratory employees (custodians, maintenance, public safety, etc.) who, during their normal course of employment, are required to perform assigned duties in or in the immediate vicinity of controlled radiation areas must be informed of the radiation hazard present. These individuals must never enter these areas when not attended by an authorized radioactive material user and must be directly supervised by an approved radiation worker while in a controlled area. If a “non-radiation use” non-laboratory employee will be performing duties in or in the immediate vicinity of a controlled area, Radiation Safety staff must be notified prior to the performance of such duties so that an appropriate exposure evaluation may be performed.
Information regarding the training required for “non-radiation use” non-laboratory employees prior to entry into controlled radiation areas is provided in Section 1.6.5 of this Handbook.
1.6 Training
(i) Radiation Worker Training
Syracuse University is obligated by 10 NYCRR Part 16 to ensure that individuals who work with ionizing radiation at the University are supervised and instructed in the hazards of radiation and related regulations and are competent to safely use radioactive materials and/or radiation producing equipment. Each individual who wishes to work with ionizing radiation at Syracuse University, therefore, must complete the Radiation Worker Training Program. This training provides an overview of principles and practices of radiation protection, monitoring techniques, biological effects, regulations and job specific instruction. Once individuals have completed the required training, they receive Approved Radiation Worker status. This status requires the completion of required annual refresher training.
The Radiation Worker Training Program consists of two stages. This Section provides a general overview of the training provided in each stage of the training program. Specific details for becoming either a Radioactive Material Worker, a Sealed Source User or a Radiation Equipment Operator are provided in Sections 2.3, 2.12.4 and 4.2.4 respectively.
Stage One: Documented and directed by Radiation Safety staff
Training in the following areas:
- Applicable regulations and license conditions (Radiation Protection Program Handbook, RSO lectures and regulatory review)
- Radiation hazards, biological effects and risk assessment (videotapes, Supervisor instruction and RSO lecture)
- Radiation safety procedures including work rules, exposure monitoring, survey instrument use and contamination monitoring (Supervisor, RSO lecture, and Handbook)
- Obligation to report unsafe working conditions
- Emergency procedures
- Right to be informed of radiation exposure and bioassay results
- Posting and License location
An examination will be given at the completion of the Stage One training requirements (with the exception of sealed source user) to evaluate the individual’s knowledge of the University’s Radiation Protection Program, biological effects, associated hazards, related rules and regulations, radiation terminology, etc.
Stage One requirements must be completed and documented prior to working with radiation (see details on exception for radioactive material users with adequate previous experience provided in Section 2.3). Following the successful completion of Stage One, conditional approval to work in radiation areas is granted. After receiving conditional approval, Stage Two training begins. Stage Two training should be completed and documented within four months of obtaining conditional approval.
Stage Two: Documented and directed by Radiation Supervisor (RMS/RES)
Training in the following areas:
- Training specific to the type of radiation work that will be performed:
a. Radioactive Material: areas where radioactive materials are stored, used and disposed; location and use of radioactive material; inventory and disposal records
b. Radiation Equipment: theory of operation; start up and shut down procedures; interlocks and safety devices
c. Sealed Source Users: areas where sources are stored and used, source use log, source security, leak tests and inventory
- RSC approved “Application for use…” conditions including approved procedures, restrictions, possession limits, etc.
- Locations of personnel exposure monitors, lab coats, gloves and monitoring equipment
- Location of radiation safety related documents, postings and manuals
- Location of eye wash, safety shower and emergency contact list
- Hazards of radiation and safety precautions specific to the laboratory
- Radioactive material workers using open sources must document 40 hours of direct supervision and instruction in related techniques and use of equipment (some or all may this requirement be waived if adequate previous experience using radioactive materials in applications similar to those anticipated to be performed at Syracuse University can be documented)
- Radiation equipment operators must document procedural training specific to the equipment that will be used, conducted by the appropriate RES
FinaI approval of radiation worker status is obtained upon the satisfactory completion and documentation of Stage One and Stage Two. This status is maintained by completing annual refresher training requirements.
Training records will be retained by EHSS for a minimum period of three (3) years after an individual has left the University.
(ii) Radioactive Materials Supervisors Responsibilities
Radioactive Material Supervisors (RMSs) shall ensure that each new radioactive material worker under their supervision completes a “Laboratory Orientation” form, has it signed by the RMS and returns it to the RSO prior to commencing any work with radioactive materials in the laboratory. Each worker must also document forty (40) hours of direct supervision and instruction on radiation related techniques and equipment specific to the laboratory. This instruction can be provided by the RMS or another approved radiation worker in the laboratory and must be documented on a “Supervised Training” form. Completed training forms must be submitted to the RSO for review and approval. Each worker should complete this process within four months of obtaining conditional approval to obtain final approval. Requests for additional time to complete this process must be made to the Radiation Safety staff.
(iii) Radioactive Equipment Supervisors Responsibilities
Radiation Equipment Supervisors (RESs) shall ensure that each new radiation equipment operator under their supervision completes a “Laboratory Orientation” form, has it signed by the RES and returns it to the RSO prior to commencing any work with radiation equipment. RESs must also provide each new radiation equipment operator with training on procedures specific to the radiation equipment to be used prior to allowing them to operate the equipment independently. This training must be documented on an “Analytical X-ray Procedural Training” form. The completed form must be signed by the RES and returned to the RSO for review and approval. Each operator should complete this process within four months of obtaining conditional approval to obtain final approval. Requests for additional time to complete this process must be made to Radiation Safety staff.
(iv) Instructions to “Non-Radiation Use” Laboratory Employees
Laboratory employees whose duties may require them to work in the vicinity of radioactive materials or radiation producing equipment must be informed of the radiation hazard present in the laboratory. These individuals will be informed of the radiation hazard through the University’s Hazard Communication Program, the Chemical Hygiene Program and/or the Radiation Protection Program, depending on the exposure potential in the laboratory and the type of work to be performed.
If a “non-radiation use” laboratory employee is to perform duties in the laboratory which may present a potential for occupational radiation exposure (dish washing, wipe testing, surveying, etc.), the individual must complete Phase I of the Radiation Protection Program’s Radiation Worker Training. This training includes attending a lecture provided by Radiation Safety staff, viewing videos and passing an examination.
The required laboratory specific, Phase II training for a “non-radiation use” laboratory employee will be based on the RMS’s completion and submittal of a “Hazard Assessment” form. The “Hazard Assessment” form must detail anticipated duties that may present a potential for radiation exposure and the proposed supervised Phase II training to be provided. The Phase II supervised training must be sufficient to ensure the individual is competent in performing the duties safely. The “Hazard Assessment” form must be submitted to and reviewed by the RSO. Notification of approval of the proposed Phase II training and any additional requirements will be provided by the RSO to the supervisor and the individual. All supervised training received by the individual must be documented. Following completion of the RSO approved supervised training, documentation of the training must be submitted to and approved by the RSO prior to allowing the individual to perform the radiation duties unsupervised. Upon receiving RSO approval, the individual may independently perform only those duties for which training was provided and competency was demonstrated and specifically approved by the RSO. “Non-radiation use” laboratory employees may not at any time perform decontamination procedures (i.e. contamination clean up) or other procedures that present a greater exposure or unexpected contamination potential.
The laboratory’s Radioactive Material/Radiation Equipment Supervisor must ensure that all individuals with the potential for personal exposure in excess of the public dose limits are properly trained prior to working in a controlled area or performing radiation-related duties.
(v) Instructions to “Non-Radiation Use” Non-Laboratory Employees
“Non-radiation use” non-laboratory employees (i.e. custodians, maintenance, public safety, etc.) whose duties may require them to occasionally access or work in the vicinity of controlled radiation areas are informed of radiation hazards through the University’s Hazard Communication Program. Radiation Safety staff provides additional training, specific to individual job requirements, to those individuals/groups whose duties may present a potential for occupational exposure. It laboratory’s Radioactive Material/Radiation Equipment Supervisor’s responsibility to ensure that all individuals who enter or work in or in the immediate vicinity of controlled radiation areas are properly trained and supervised, as necessary, prior to working in or in the immediate vicinity of the Supervisor’s controlled radiation area(s). Only authorized personnel are allowed contact with containers, work areas, etc. identified with radiation hazard labels, symbols or tape.