With Ionising Radiation In

MANAGEMENT OF WORK WITH IONISING RADIATION IN QUEEN MARY, UNIVERSITY OF LONDON (QMUL)

QM/H&S/0072 Version 01/06/2006 Index

1. General Policy

2 Management of Radiation Protection 2.1 College Management Structure p3 2.2. Role of Responsible Bodies/Persons including Heads of Departments and Directors of Institutes p3 2.3 Training of Staff p5 2.4 Radiation Safety Incidents p5

3 Control of Radiation Work Areas 3.1 Definition of Radiation Work Areas p5 3.2 Design and Maintenance of Radiation Facilities p6 3.3 Access to Radiation Work Areas p6 3.4 Decommissioning of Radiation Work Areas p6

4 Control of Radioactive Materials and Sources 4.1 Registration of Work with Radioactive Materials p6 4.2 Ordering and Delivery of Radioactive Materials p7 4.3 Control of Radioactive Materials in College Premises p7 4.4 Storage and transfer of Radioactive Materials p7 4.5 Disposal Radioactive Waste p7

5 Control of X-ray Equipment 5.1 Purchase and Registration of X-ray equipment p8 5.2 Installation and maintenance of X-ray equipment p8 5.3 Disposal of X-ray Equipment. p8

6 Medical Uses Of Radiation 6.1 Control of Medical Exposures p8 6.2 Equipment used for Medical Exposures p8

7 Monitoring 7.1 Personal Monitoring p9 7.2 Environmental Monitoring p9 7.3 Monitoring of Surface Contamination p9 7.4 Calibration of Monitors p10

8 Compliance with Best Practical Means (BPM) 8.1 Minimisation of Usage p10 8.2 Prior Risk Assessment and Authorisation p10 8.3 Review of facilities p11 8.4 Staff Training p11 8.5 Auditing of Local Rules p11 8.6 Contamination and Spillage Control p11 8.7 Waste Management p11 8.8 Laboratory Auditing and Reporting p12 8.9 Security and Fire Prevention p12

9 Appendices

2a QMW Organisational Structure p15 2b Principal’s Steering Group p16 2c QMW Committee Structure p17 2d Responsibilities for Radiation Safety p18 2e Terms of Reference for the Radiation Protection Sub-committee p19 2f List of Appointed Postholders p21 2g Duties of Postholders p22 2h Accident and Dangerous Occurrence Report Form p24 2i Local Rules for Charterhouse Square Campus p25 2j Local Rules for West Smithfield Campus p30 2k Local Rules for Whitechapel Campus p33 2l Local Rules for Mile End Campus p43 4a Project Approval and Risk Assessment p46 4c Radiation Sources order Form p56 4d Monthly Return Form for Isotope Disposal p57 8a Radioisotope Departmental Audit Form p58 8b Radioisotope Room Audit Form

QM/H&S/0072 Version 01/06/2006 1. General Policy

The ultimate responsibility for the implementation of radiation protection measures rests with the College Council.

This document and attached appendices and “Local Rules” describes how the College manages radiation protection to ensure compliance with the legal requirements laid out in the Ionising Radiations Regulations 1999 (IRR99), the Radioactive Substances Act 1993 (RSA 93) and the Ionising Radiation (Medical Exposures) Regulations 2000 (IRMER) in order that exposures to staff and students using sources of radiation on College premises, and those who might be affected by their activities, are kept as low as reasonably practicable (ALARP). The document also describes how the College will adopt best practical means for the storage, use and disposal of radioactive wastes.

This is a living document subject to modification as agreed by the Council of Queen Mary and Westfield College and gives effect to all policy and procedures concerning Radiation Protection. The document is available to all College staff on the College internet website.

2. Management of Radiation Protection

2.1 College Management Structure

The general organisational structure is shown in Appendices 2a, 2b and 2c. A simplified structure relevant to radiation protection is in Appendix 2d.

There is a chain of responsibility which originates with the College Council and Principal and passes down to Heads of Departments (HOD) and Directors of Institutes (DIO),. The Principal, HOD and DIO are advised in matters of radiation safety by the College Health and Safety Committee and its sub-committee, the Radiation Protection Safety Committee, through Principals Steering Group (PSG) as shown in Appendices 2 a and 2c. The College Radiation Protection Adviser (RPA) sits on both committees. The College RPA also has direct access to relevant senior managers and the PSG.

Day-to-day supervision and control of radiation within Departments and Institutes is exercised by Radiation Protection Supervisors (RPS) appointed by, and answerable to, Heads of Departments/Institutes with the advice of the RPA.

The terms of reference of the College Health and Safety Committee and those of the Radiation Safety Committee are in Appendix 2d

This document is available to all College staff on the College Internet and gives executive level backing to the following policy and procedures:

2.2 Roles and Responsibilities of Staff for Radiation Protection

2.2.1 Heads of Department and Directors of Institutes

(i) The HOD or DOI is responsible for all aspects of radiation safety in his/her department, including ensuring there is adequate funding to meet the requirements of this policy and the Local Rules for the work carried out in his/her department

(ii) In consultation with the College RPA, the HOD/DOI must appoint suitably qualified Radiation Protection Supervisors and, if necessary, deputies.

(iii) The HOD/DOI must ensure that where appropriate new staff receive induction and training in radiation safety.

(iv) The HOD/DOI must notify the RPA, and the Radiation Protection Supervisor as soon as a pregnancy has been declared by a member of staff so that the necessary precautions can be taken to ensure that the dose received by the foetus during the term of pregnancy is restricted.

QM/H&S/0072 Version 01/06/2006 (v) The HOD/DOI must ensure that any change of procedure, equipment or environment which may affect the radiation safety precautions in the Department are reported to the College RPA.

2.2.2 The College Radiation Protection Adviser (RPA)

The RPA's function is to advise the College on all matters concerned with compliance with the IRR99, IRMER and RSA 93 and any other relevant regulations. In strict legal terms this post does not carry the responsibility for implementing the Regulations.

2.2.3 College Safety Records Administrator (SRA)

The College SRA is a member of the Health and Safety Department who will take responsibility for administration of the College Radiation Protection Management system, including the ISOSTOCK isotope inventory system, in collaboration with the RPA and RPS. A primary function will be to ensure College compliance with Best Practical Means in radiation safety from both the environmental and Health and Safety .

2.2.4 The Departmental Radiation Protection Supervisor (RPS)

These are members of staff responsible for supervising the work with radiation to ensure compliance with Local Rules within the group or department in which they normally work. The RPS’ has the authority to exercise control over radiation workers in their department and must keep their HoD/DOI appropriately informed. They must be trained, and experienced workers in the use of sources of ionising radiation and will normally be available during working hours.

(i) The Radiation Protection Supervisor must oversee, and observe from time to time, the work with ionising radiation in the department for which she/he is appointed so that it is carried out in accordance with the Local Rules for that department. The RPS will give any instructions necessary to maintain doses to staff and members of the public as low as reasonably practicable.

(ii) The Radiation Protection Supervisor must ensure that local rules are brought to the attention of all relevant staff and a record of this kept

(iii) The RPS must make sure that any personal monitoring devices issued are used in the correct manner.

(iv) The RPS must instruct departmental staff in safe working practices. Maintenance staff must also be given appropriate instructions when they are required to work in radiation areas in the Department.

(v) The RPS must help establish and maintain operational procedures that ensure staff exposures are kept AS LOW AS REASONABLY PRACTICABLE (ALARP)

(vi) When it is suspected that a radiation incident or hazard has arisen which might give rise to significant exposure or contamination, the RPA must be informed as soon as possible by telephone, and IN WRITING by the RPS. The RPS must also inform the RPA of any maintenance, servicing or procedural changes, new techniques or new equipment which may require protection investigation.

(vii) The RPS must be responsible for accurate record keeping within the department and the security of sources

(viii) The RPS must ensure the disposal of radioactive waste for his/her group does not contravene the College's EA Authorisation.

(ix) When necessary adequate supplies of suitable protective clothing must be maintained by the RPS in consultation with the Head of Department.

(x) The RPS, after consultation with the RPA and the College Safety Adviser, must provide any maintenance personnel or visiting service engineer who has to enter any area where contamination is possible for purposes of maintenance, with an appropriate written permit to work.

QM/H&S/0072 Version 01/06/2006 2.2.5 Occupational Health Physician

All medical aspects of radiation protection are the concern of the Occupational Health Physician.

2.2.6. Radiation Workers

All persons exposed to ionising radiations in the course of their work are categorised in one of two groups; Classified or Non-classified, according to the areas in which they work and the annual doses they are liable to receive. The extent of medical and dosimetric supervision they receive is also related to these categories.

Classified Workers

All persons working regularly in Controlled Areas (see below) and whose doses might exceed three- tenths of any dose limit are designated as Classified Workers. They must be at least 18 years of age and may be men or women, but women of reproductive capacity are restricted in the rate at which they may reach their annual dose limit.

Classification of workers is normally avoided by strict control of radiation exposure. This is the approach which is used in the College. There are currently no classified workers in the College.

Non-classified workers

Persons who work in Controlled or Supervised Areas and who are unlikely to receive doses in excess of 3/10 of any worker dose limit but may receive more than 1 mSv per year (the public dose limit) are designated as non-classified workers. They do not normally receive medical supervision, but their doses are assessed in the same way as Classified Workers.

For the purposes of safety control, all people working in the College with radiation or radioactive material will be taken to be non-classified workers.

It is emphasised that people who work in Controlled Areas but are not classified radiation workers in the College must do so under a written Scheme of Work (See Section 3.2 below).

2.3 Staff Training . Each year the Health and Safety Department runs several one day “Working with Radioactive Isotopes” training courses. These courses are intended for all persons working with radioactive substances and are supplemented by two specialist RPS training courses.

Either the HOD, the DOI or the RPS responsible for a group must ensure all new users of radioactive material attend the College one day radiation training course unless they have proof of competency from another source. Radiation risk assessment training is an integral part of the training course. A copy of the appropriate Local Rules document, which provides a comprehensive guide to best practice in radiation safety, including background information, is given to each user for reference (Appendix 2 h).

There are courses organised by the University of London at different Colleges throughout the year and courses are also arranged by the College RSC as the need arises.

2.4 Radiation Safety Incidents

Radiation incidents such as spillages of isotopes, accidental exposure, loss of sources or isotopes, near misses, etc. should be reported to the Health and Safety Office as soon as possible by phoning 13 5431, 13 6036 or 13 5310. An accident report form, HS/A2005 (Appendix 2h ) must be completed and returned to the Health and Safety Office. The incident must also be reported to the College RPA and to the appropriate HoD/DoI by phone and by copying the accident report form to them.

3. Control of Radiation Work Areas

3.1. Definition of Work Areas

QM/H&S/0072 Version 01/06/2006 All working areas in which sources of ionising radiation are used, are designated according to the potential health hazard of the work carried out in the area. Separate assessments are made in terms of external and internal hazards.

The two types of areas are Controlled Areas and Supervised Areas, as defined in IRR99.

A Controlled Area is defined as an area any person who enters or works in the area must follow special procedures to restrict significant exposure to ionising radiation, or is likely to receive an effective dose greater than 6 mSv a year, or an equivalent dose greater than 3/10th of any dose limit.

A Supervised Area is defined as an area where work condition must be kept under review, and where a person is likely to receive an effective dose greater than 1 mSv a year, or an equivalent dose greater than 3/10th of any dose limit.

In practice, it is relatively easy to decide the grading in terms of the external hazard, by means of prevailing dose rates measured by means of a dose-rate meter and assuming standard working times. It is much more difficult, and in some cases impossible to make comparable measurements of internal dose received, so other quantities such as surface contamination or airborne contamination are measured. These are known as derived working limits (DWL). Alternatively, it is possible to base the area grading on the total quantity of unsealed radioactive substances present expressed in terms of the annual limits on intake (ALI) (see Appendix I). This is arbitrary and not proscribed by the IRR but is effective in restricting exposure and is general practice in the College. Quantities in each of the three categories are as follows:

Numbers of ALI's

Minimum Maximum Controlled areas 10 - Supervised areas 3 10 All other areas 0.3 3

Values of ALI for a selection of radionuclides are given in Appendix III.

The size of a Controlled or Supervised Area can vary widely. For example, a fume cupboard may constitute a Controlled Area, but the room in which it is situated may only be a Supervised Area, based on its environmental conditions. In general Supervised Areas will tend to be part of a larger laboratory where other, non-radiation work may be in progress.

Signs indicating the classification of the area from the point of view of external dose and contamination, must be fixed at every entrance and the demarcation of such areas must be clear. Plans showing the precise location and extent of all Controlled and Supervised Areas form part of the Master Copy of these Rules.

Plans showing the precise location and extent of all Controlled and Supervised Areas are shown in the Master Copy of the Local Rules for each site.

3.2 Design and Maintenance of Radiation Facilities

Facilities where radiation work is to be carried out must be designed to ensure that doses to staff and students and members of the public are kept as low as reasonably practicable and, where unsealed radioactive sources are used, the layout and facilities should minimise the spread of contamination, while all surfaces should be constructed to facilitate decontamination.

When new facilities are planned, or are being upgraded, the HoD/DOI must ensure that the RPA and the Health and Safety Adviser are consulted early in the design stage. New facilities should comply with the guidance given in the Medical and Dental Guidance Notes (IPEM 2002) and the Guidance on Standards for Radiochemical laboratories in Non-Nuclear Premises given in the Environment Agency Field Officers Handbook (EA website).

Records must be kept of any installed shielding, and of the radioactive drain and vent disposal routes, including a map of the routes.

Existing facilities must be maintained to ensure that surfaces remain non-absorbent.

QM/H&S/0072 Version 01/06/2006 The design must ensure that radioactive materials are securely stored and that access to the radioactive work areas is restricted.

3.3 Access to Radioactive Work Areas

Entry to Controlled Areas is restricted to those persons authorised to do so. .

Only Classified Workers are permitted to work regularly in Controlled Areas. Other persons, including laboratory, visitors, maintenance and service personnel, can enter these areas only if a written Scheme of Work is prepared designed to ensure that they cannot receive more than 6 mSv effective dose per year or three-tenths of any other dose rate limit.

This Scheme of Work should be written by the departmental RPS and approved by the College RPA. This scheme of work is part of the approval initially given to use radioactive materials or radiation emitting devices which MUST be obtained before any project is started. A copy of the written Scheme of Work must be available to anyone entering the area and its terms must be understood. A further copy will be deposited in the Master Copy of the Local Rules.

Specific measures must be implemented to restrict entry to Controlled Areas, to those persons authorised to do so. Regular surveys for radiation and contamination (surface and airborne) as appropriate must be carried out in all Controlled and Supervised Areas. The results of these surveys must be recorded and kept for 2 years.

Signs complying with BS 3510:1968 and incorporating information on the nature of the hazard (i.e. radiation or contamination) and the designation of the area (i.e. Controlled or Supervised) should be fixed at every entrance to areas in which radiation sources or radioactive substances are present.

A suitable dose-meter must be readily available at all times, when work involving exposure to external radiation is in progress.

A contamination meter with appropriate detector must be available at all times when work is in progress with unsealed radioactive substances. This meter must be checked and re-calibrated every 14 months.

If an area in which unsealed radioactive substances have been used, ceases to be used for this purpose, a rigorous monitoring and decontamination procedure must be carried out and a written clearance certificate provided by the vacating department.

Note in summary:- The only persons permitted to enter or remain in a controlled laboratory or area are:- (a) Classified Staff. (b) Other staff following a written scheme of work approved by the RPA. As there are no classified staff on the Charterhouse Square site but there are controlled areas, a written and approved scheme of work is essential. (c) Visitors or maintenance staff following a written scheme of work, with the express approval of the RPS.

Note that the rules covering work in Supervised areas cover domestic cleaning staff and visitors. Cleaning staff should only clean floors in laboratories where radioactive materials are used and not touch benches, equipment, sinks or waste containers. Visitors who could include service engineers should obey the RPSs rules - visitors should not include children under 16.

3.4 Decommissioning Radioactive Work Areas

If an area in which radioactive substances have been used, ceases to be used for this purpose, a rigorous monitoring and decontamination procedure must be carried out and a written clearance certificate provided by the vacating department. Copies of the clearance certificate must be sent to the College RPA and to the College Health and Safety Adviser and a final inspection of the area, including monitoring carried out by the RPA.

4.0 Control of Radioactive Materials and Sources

4.1 Application to Work with Radioactive Materials

QM/H&S/0072 Version 01/06/2006 Before any new work, or significant change of existing work, can be undertaken, the work has to be registered with, and approved by, the College RPA. The registration must have an accompanying radiation risk assessment that must be approved by the RPA. These forms are attached as Appendices 4a and 4b.

Before ordering radioactive materials an experimental protocol must be agreed (in writing) between the researcher, his/her departmental RPS and the College RPA. This protocol must stress the radiation safety precautions in terms of a risk assessment, minimisation of radio-isotope usage and the pathways for waste disposal. It is an approved scheme of work which is kept available for inspection in the work area.

4.2 Ordering and Delivery of Radioactive Materials

Ordering of radioactive materials shall only be done by a designated person or persons, usually a RPS, within each department.

Radioactive material/sources are ordered using a Radioactive Material Order Form (see appendix 4c). At Whitechapel all isotopes are ordered through the site radioactive source co-ordinator.

The material/source is delivered directly to the department (Mile End) , to a site isotope reception co- ordinator (Whitechapel) or to a post reception point where it is locked in a secure room until collected by the department RPS (Charterhouse), or to the Trust Nuclear medicine Department (West Smithfield)

4.3 Control of Radioactive Materials within the College

Each worker must keep source usage and disposal records either on the College ISOSTOCK computer database or as a hard copy which is available for inspection. These data must be sent each month by each RPS to the RSC on the appropriate form (Appendix 4d). Repeated failure to make timely returns will result in a letter to the Head of Department/ Director of Institute informing them of this situation with a request for immediate resolution of the breach of protocol. Should this fail to resolve the situation the issue would be taken up by the RSC with the appropriate College Vice-Principal.

Unsealed material, both primary sources and dilutions, must have an identity label with the isotope source code, date and activity, which must be fixed to the vessel in which it is contained. If the material is being used in a fume cupboard or in several containers then an identity card should accompany it.

All department holding sealed sources must keep a sealed source inventory, giving details of the radionuclide, activity, date acquired and eventually date disposed of and disposal route. This inventory must be copied to the RSC annually. All sealed sources are accompanied by an identity card, a copy of which is held by the Radiation Protection Supervisors and Radiation Protection Adviser. If the source is moved from its normal location for any length of time within the Department or to another Department the RPS and RPA must be informed.

4.4 Storage and Transfer of Radioactive Materials

Radioactive materials must always be used and stored in conditions which do not present a hazard to other persons in the vicinity and are reasonably secure against theft or unauthorised tampering. All materials not in regular use must be kept in a locked store, which may be a refrigerator.

Containers used to transfer radioactive materials to and from a store should be designed to reduce to a reasonable level the dose received by persons carrying them and should be designed to avoid a spill if they are dropped or upset.

The Fire Brigade must be informed of stores in which the quantities of radioactive materials could constitute a hazard to firemen in the event of a fire.

4.5 Disposal of Radioactive Waste

Routes of disposal are agreed with the RPS and the RPA before work starts. The RPS has day to day responsibility at a local level for the supervision of accumulation and disposal of radioactive

QM/H&S/0072 Version 01/06/2006 waste. Their name is on the document that is displayed with the Authorisation / Registration certificates in the Controlled Areas..

Only authorised routes of disposal must be used and records kept of day-to-day disposals. The generation of solid waste is minimised by:-

(a) Using the very minimum amount of radioactivity necessary for a given experiment. (b) Storage of short-lived isotopes for (physical) decay, subject to EA authorisation.

On the Whitechapel and Smithfield campuses the waste is transferred to Barts and The London NHS Trust. Solid waste consignments from departments to the site central waste stores are accompanied by transfer forms detailing reference information and owner of waste. These are handed directly to trained Radiation Safety staff from Barts and The London NHS Trust who manage the waste stores.

5.0 Control of X-ray Equipment

5.1 Purchase and Registration of X-ray equipment

Prior to the purchase of X-ray equipment an X-Ray equipment registration and risk assessment form must be completed and approved by the RPA. The registration forms must also be completed for existing X-ray equipment.

5.2 Installation and maintenance of X-ray equipment The installer of any equipment producing ionising has a duty under regulation 31(2) of IRR99 to undertake a critical examination of the installation together with an RPA. Arrangements must be made by the Head of Department during procurement to establish whether the College RPA or the installer’s RPA oversees the critical examination.

The equipment must be maintained and serviced according to the manufacturer's recommendations by a company qualified to carry out such maintenance

5.3 Disposal of X-ray Equipment.

X-ray equipment must be made incapable of being reused before disposal. It is likely that the X-ray tube head / cooling oil will require separate disposal. The X-ray tube may have a beryllium window and must be disposed of as hazardous waste. Care must be taken not to damage the window during disassembly since toxic beryllium dust may be released.

6.0 Medical Uses of Radiation

6.1 Control of Medical Exposures

Medical uses of radiation within the College must also comply with the Ionising Radiation (Medical Exposure) Regulations 2000 and will be carried out within an overall management framework defined by Standard Operating Procedures prepared by the College. Medical examinations will only be carried out where there is sufficient medical justification, and radiation doses to patients will be kept as low as reasonably practicable consistent with the intended clinical outcome. Where necessary, there must be co-operation with Barts and The London NHS Trust.

6.1.1 Practitioners and Operators The practitioner is the person responsible for the justification of the exposure, operators are people involved in tasks that affect the extent of the exposure. Both practitioners and operators are responsible for keeping exposures as low as reasonably practicable, according to the scope of their duties.

The practitioner for Nuclear Medicine investigation must ensure that he/she holds a current ARSAC certificate.

The College will insure that all staff authorised to act as practitioners and operators are adequately trained, and that a register of the staff is kept to include their name, date and nature of initial training.

6.1.2 Medical Physics Experts

QM/H&S/0072 Version 01/06/2006 The College will appoint Medical Physics Experts in Diagnostic Radiology and Nuclear Medicine to advise on optimisation on medical exposures.

6.1.3 Diagnostic Reference Levels and Dose Audits The College will ensure that diagnostic reference levels are set for medical examinations and that patient doses are audited against the diagnostic reference levels on a three year rolling programme.

6.2 Equipment used for Medical Exposures

Any equipment which is used in connection with a radiation exposure must be designed, constructed, installed and maintained so that the objectives of diagnosis, treatment or research can be achieved with the minimum of radiation exposure.

The installer of any equipment intended to be used in connection with medical exposures has a duty under regulation 31(2) of IRR99 to undertake a critical examination of the installation together with an RPA. Arrangements must be made by the Head of Department during procurement to establish whether the College RPA or the installer’s RPA oversees the critical examination.

Arrangement must be made, either with the installer or another party, to ensure electrical and mechanical safety testing is carried out prior to the acceptance test.

Newly installed equipment must undergo acceptance testing under the supervision of the RPA or Medical Physics Experts before the unit is put into clinical use. An acceptance test report must be provided by the RPA / Medical Physics Expert.

An equipment quality assurance programme that complies with the recommendation of the IPEM 77 Report (Recommendation Standards for the Routine Performance Testing of Diagnostic X-ray Equipment) 1997 or later revisions must be in place.

A maintenance contract must be in place to provide routine preventative maintenance on all diagnostic equipment.

Equipment requirements and performance must be reviewed and an equipment replacement plan in place.

7.0 Monitoring

An important element in the successful control of hazards from radioactive materials or other sources of ionising radiation systematic is monitoring of radiation levels. Several different types of instrument are required since no single instrument is suitable for all types of radiation; it is customary in some cases to use more than one pattern of instrument for a single measurement.

This section is intended only as a guide to users. Further information and advice on the choice of suitable monitors may be obtained from the RPA. There must be at least one contamination meter available in every laboratory where unsealed radioactive materials are handled and a dose-meter must be available in areas where gamma emitters are used. Equipment for hand monitoring must be provided near the washing area associated with all Controlled and Supervised Areas.

Monitoring can be divided into (a) personal, (b) environmental, (c) surface contamination.

7.1 Personal Monitoring

The purpose of personal monitoring is to assess the dose received by the individual. The main concern is with the whole-body dose from external radiation, but doses to particular areas such as the fingers or eyes may also be important. The doses to internal organs from radioactive materials which have entered the body are difficult to assess and special methods are necessary.

Whole-body external doses are assessed in the College by film badge and/or thermoluminescent dosimeters (TLD) which should be carried at waist level. Further TLDs elsewhere on the body may be useful, e.g. finger-tip doses are measured by a different type of thermoluminescent dosimeter. The requirements for personal monitoring will be determined in the risk assessment made for each project / use of radiation.

QM/H&S/0072 Version 01/06/2006 Personal monitoring is provided by the Clinical Physics Group, Barts and the London Trust and distributed through the Departmental RPS. Each dosimeter is numbered and is for use by one person only. Monthly reports of doses are sent to the Radiation Protection Supervisors. In addition if any monthly doses exceed the monthly reporting level (0.33 mSv for whole body doses, 4.2 mSv for extremity doses) a blue card will be sent to the RPS requesting information on how this dose could have been received.

Direct measurement of internal doses is not carried out by the College on a routine basis. However, if a worker is regularly handling large quantities of certain radionuclides, such as the low energy beta emitters tritium and carbon-14, he or she may be required to provide urine samples, usually on a 'spot check' basis. Workers handling large quantities of radioactive iodine will also have the thyroid regularly monitored with an appropriate contamination monitor.

7.2 Environmental Monitoring

The purpose of environmental monitoring is to find the areas in which appreciable dose-rates exist so that appropriate measures, such as provision of shielding or restriction of working time, may be taken to reduce the dose to personnel. It is not a substitute for personal monitoring.

Environmental monitoring should be carried out during and immediately following the installation and testing of new equipment or following any alteration in experimental arrangements. With equipment producing x-rays, once the pattern of radiation has been established subsequent surveys can be less detailed. Where sealed or unsealed radioactive materials are handled, surveys should be more frequent since the materials are normally moved fairly often, thus changing the distribution of radiation in the area.

7.3 Monitoring for Surface Contamination

Environmental and personal surface contamination monitoring is required in areas where unsealed radioactive materials are handled.

The most common type of instrument is a rate-meter, to which a suitable probe may be attached. The choice of probe depends on the isotopes being monitored (Appendix Va).

Wipe or smear testing can also be used for monitoring for surface contamination. In areas possibly contaminated with tritium, carbon-14 or sulphur-35 surface wipes should be counted by liquid scintillation It is normally assumed that about 10% of the removable contamination is transferred to the paper and that levels may be averaged over 0.1m2 for floors, ceilings and walls, or 0.03 m2 for other surfaces; for parts of the body, integration over an area of 0.01 m2 or a whole hand is permissible. Monitoring must be carried out at the end of each work session using unsealed radioactive sources and the results recorded.

Sealed sources must be checked for leakage at regular intervals, at least once in two years or whenever there is a suspicion of leakage, e.g. after damage or suspected damage to the source container.

7.4 Calibration of Monitors

All instruments used for radiation and contamination monitoring should be delivered from the manufacturer with a certificate indicating how the instrument reading differs from the absolute value, at various points on the range. The calibration procedure should also include response of the instrument under varying conditions of temperature and humidity. Subsequently, at intervals of not more than a year, or following any servicing or repair of the instrument, other than replacement of batteries, the response of the instrument should be checked again and the results noted The monitors will need to be sent to an external contractor for calibration.

8.0 Compliance with Best Practical Means (BPM)

8.1 Minimisation of Radioisotope Usage

Review of experimental procedures

QM/H&S/0072 Version 01/06/2006 Each new project is individually reviewed. The activity and volume of radioactive waste are minimised by encouraging the substitution of radio-isotopes methods with none radioactive methods where-ever possible. This is reinforced during the user training sessions and in the project approval process where RPS and project supervisors are asked to consider other, non-radioactive or less radioactive, techniques.

Review of medical procedures

All diagnostic investigations have diagnostic reference levels set as required IRMER. Work will not proceed until the proposed project registration has been authorised by the RPA. Activities are optimised in accordance with patient dose and image quality thereby minimising the dose to the patient minimises the discharge to the environment.

8.2 Prior Risk Assessment and Authorisation of Work

A risk assessment is required for all work and will be signed off by the RPA (or a member of his/her team) when they are satisfied about all health and safety and environmental considerations. Risk assessments will be carried out using a common methodology developed by Guy’s and St Thomas’ Hospital Trust (Appendix 4 a).

8.3 Review of facilities

New facilities will be designed to facilitate decontamination and to minimise the spread of contamination. Existing facilities will be inspected annually at audit visits and where necessary the facilities repaired / maintained.

8.4 Staff Training

As set out in section 2.3 above, there are several one day radiation training courses and in addition two specialist RPS training courses each year. There will also be an annual meeting of the College RPA , the Health and Safety Group and the departmental RPS. This will act as a forum to cascade information down to RPS as well as providing feedback to the Health and Safety Group.

8.5 Audit of local rules and work procedures

Local rules are audited every year by Health and Safety in collaboration with the College RPA. RPSs will be notified of any significant changes necessary due to changes in legislation, contact details of staff etc. Local Rules for each site are available electronically to all departments on the Health and Safety website. Copies of local rules are held by the RPA and RPS’.

8.6 Contamination Control. Departmental and Laboratory audits (Appendix 8a & 8b) examine the control measures being taken and state whether these are adequate; specifying what modifications to procedures are necessary to comply with best practice. These are identified in the department radiation risk assessments.

Contamination records are inspected during annual laboratory audits (Appendix 8a, 8b). All departments are required to have suitable monitors to detect contamination from the open source radioactive material in their areas (Section 7 above). These are tested and calibrated annually by the College Radiation Safety Co-ordinator (RSC) and carry a calibration sticker to confirm the date of calibration. All monitoring equipment is inspected for calibration and battery status during the annual audit from Radiation Safety. Where contamination cannot be detected by a monitor, wipe testing and scintillation counting are performed and recorded.

Actions to be taken in the event of a spill are included in the local rules and each department has one or more spill kits.

8.7 Waste Management.

Waste management procedures are detailed in section 4.4 (above) and in the Local Rules.

Departments are required to segregate waste at source according to isotope, waste type and disposal stream. Organic scintillant waste is sent regularly to a central organic solvent waste store and solid radioactive waste regularly to a central solid waste store, located on each campus.

QM/H&S/0072 Version 01/06/2006 Health and Safety manage the solid radioactive waste stores at Charterhouse Square and Mile End. Solid waste at the Whitechapel and Smithfield campuses is transferred to the Radiation Safety Section, Barts and London Trust, who manage the Trust waste store. Waste is stored for decay until disposal as either solid waste, very low level waste or non-active waste in accordance with the EA site authorisations, as identified in the project registration and risk assessments.

Short-lived radionuclides / low activity waste can be stored for decay until it disposed of as either non-active waste or very low level waste as appropriate

The waste store is open for a specific hand over period only where a member of Radiation Safety formally accepts the waste and receives forms detailing the contents of each bag. Solid radioactive waste is not accepted without adequate documentation.

The data collected from this documentation are used, in conjunction with the monthly summaries returned by each RPS, to check all Authorisation accumulation and disposal limits.

8.8 Audit and Reporting Schedules.

Department and laboratory audits are scheduled and performed annually (as described under section 2.2 above). Departments may also be inspected at other times such as when setting up of new facilities or decommissioning of old rooms etc. The organisation of audits is detailed in the quality system procedures and work instructions outlined above. An example of an audit checklist is attached in Appendix F

8.9 Security and Fire Prevention.

Fire: All areas linked to central smoke detector and Fire Alarm system. Fire procedures are in place for all sites.

Security: All department using radioactive materials must ensure that access to the radioactive work areas is restricted and locked when not in use. All radioactive material is stored in lockable safes, fridges or freezers. The sites are inspected by the EA and CT branch of New Scotland Yard and recommendations have been implemented.

QM/H&S/0072 Version 01/06/2006 APPENDICES

QM/H&S/0072 Version 01/06/2006 Appendix 2 a

QM/H&S/0072 Version 01/06/2006 Appendix 2 b

QM/H&S/0072 Version 01/06/2006 Appendix 2 c

QM/H&S/0072 Version 01/06/2006 Appendix 2 d Responsibilities for Radiation Safety in Queen Mary and Westfield College

Council of Queen Mary and Westfield College

Principal

College Health and Safety Principal’s Steering Group Committee

Radiation Protection Safety Committee

Radiation Protection Warden of School of VP Science and Engineering Adviser Medicine and Dentistry

Radiation Protection Directors of Institutes in the Heads of Depts/Schools Co-ordinator SMD Science and Engineering

Section Heads Research Supervisors

Radiation Protection Radiation Protection Supervisers Supervisers

Radiation Workers Radiation Workers

Line management responsibility

Advisory and administrative responsibility

QM/H&S/0072 Version 01/06/2006 Appendix 2 e

Terms of Reference for the Radiation Protection Sub-committee of Queen Mary and Westfield College

Terms of Reference The Health and Safety Committee agreed the following generic terms of reference: (1) to advise the Health and Safety Committee on such actions as are necessary to comply at least with statutory and sub-statutory requirements, and College health and safety policy. In this connection, the sub-committee will have regard to any contemporaneous code of best practice promulgated by the Universities & Colleges Employers Association or any other relevant professional body. (2) to advise Heads of Departments, Schools and Institutes, and the Health & Safety Committee of what is required as a minimum to meet the legal requirements and responsibilities for health and safety. (3) to keep under review the implementation and effectiveness of health and safety, and arrangements to monitor safety standards and performance in those parts or activities of the College for which the sub-committee has responsibility. In connection with this it will give particular attention to the elimination and reduction of hazards and control of risks. (4) to advise and review measures for the promotion and awareness of safety in those parts or activities of the College for which it is responsible. (5) to recommend to the Health & Safety Committee performance measures and targets by which the sub-committee’s performance may be assessed, and to submit an annual report to the Committee on its progress in achieving such targets. (6) to be advised by the central health and safety staff employed by the College, including the Occupational Health Service and other relevant policy holders. (7) to heed and give effect to any relevant Codes of Practice, and in particular to that published by UCEA. (8) to make recommendations to the Health & Safety Committee as to what activities or authority should be delegated to the sub-committee, and to undertake such duties as may be delegated by the Committee. (9) to establish working groups or other bodies to undertake specific tasks on behalf of the sub- committee. (10) to audit the activities of the sub-committee at least once a year and to report annually to the Health and Safety Committee. Each sub-committee will be asked to review their terms of reference and recommend any additions to the Health and Safety Committee for approval.

Membership of the sub-committees Members of the sub-committees will be appointed by the Health and Safety Committee for a term of office of normally four years. The Chair of each sub-committee will be in attendance at the Health and Safety Committee. The membership of the sub-committees should be as inclusive as possible to reflect their responsibilities. In this way the sub-committees can both reflect the views of their constituents and assist in communicating a health and safety culture across the College. Membership should include:  A Chair;  A Deputy Chair;  Staff representing the disciplines or subjects covered by the sub-committee;  Departmental safety representatives (where appointed);  Students representing the disciplines covered by the sub-committee;  Trade union safety representatives;  Health and Safety Advisers from the Health and Safety Office

Activities of sub-committees

04/04/2018 19/63 Radiation Protection sub-committee The Chair of this sub-committee will be Professor Jacky Burrin. The terms of reference will include:  Responsible for advice on health and safety of ionising and non-ionising radiation as it might affect any staff or student in the College;  Responsible for ensuring that the latest legal requirements on radiation are communicated to relevant staff and students.

04/04/2018 20/63 Appendix 2 f

List of Appointed Postholders

1. Chair of Radiation Protection Committee is Professor J M Burrin (Telephone 020 7601 7645)

2. The current RPA is Dr J Horrocks Consultant Physicist, Medical Physics Barts and the London Trust. (Telephone 020 601 8291)

3. The current Laser Safety Adviser is Professor D Dunstan, Head of Department, Dept of Physics, QMUL . (Telephone 020 7882 3687.)

4. The College Occupational Health Physician is, Occupational Health. (Telephone 020 7882 3176)

5. Current lists of Radiation Protection Supervisors and Laser Protection Supervisors are kept by the RSC and RPA and are included in the local rules

04/04/2018 21/63 Appendix 2 g

Duties of Postholders

Duties of the Radiation Protection Adviser

To advise the employer on all matters relating to radiation safety and compliance with the legislation listed in Appendix 3.

Typically this will include advice in the following areas:-

1. Designation of controlled and supervised areas

2. Designation of classified staff

3. To advise on the adequacy of radiation risk assessments

4. To review radiation doses received by staff to ensure they are as low as reasonably achievable

5. Control of access to controlled areas

6. Contingency arrangements

7. Selection of Radiation Protection Supervisors

8. Appraisal of Local Rules

9. Selection and calibration and use of monitoring equipment

10. Leak testing of sealed sources

11. Training needs

12. Review adequacy of arrangements for keeping radioactive sources.

04/04/2018 22/63 Duties of the Laser Protection Supervisor

1. To ensure that the local rules and the Ionising Radiation, Laser & Ultraviolet Radiation Safety Policy are adhered to.

2. To inform the L.P.A. if they consider that the existing local rules require amending.

3. To ensure that the register of Authorised Operators is maintained.

4. To ensure that all relevant staff read and understand the local rules and sign a statement to that effect. (these statements are kept by the LPS.)

5. To ensure that only Authorised Operators use the laser.

6. To inform the L.P.A. as soon as possible in the event of a laser safety incident occurring.

7. To seek advice from the L.P.A. on the safety implications when a change of procedure is envisaged.

04/04/2018 23/63 Appendix 2 h

FORM HS/A2005 QUEEN MARY, UNIVERSITY OF LONDON

ACCIDENT AND DANGEROUS OCCURRENCE* REPORT

PLEASE COMPLETE ALL SECTIONS USING BLOCK CAPITALS THROUGHOUT (Use back of form for extra information if necessary)

Send completed form to: Mrs M Giguere, Health and Safety Office, Mile End. Tel ext: 13 5310

Name of person reporting incident: ______Tel. ext: ______

Date of Incident ___/___/200 Time of Incident ___:___ Location of Incident* Charterhouse Sq Date Reported ___/___/200 Mile End Whitechapel W Smithfield Other location Data on injured person

Surname:______

Forenames: ______Age____ Sex M/F*

Address; Home/Term time______

Department/Institute:______Tel ext: ______

Where did the accident/occurrence* happen? (Building and room number or external location)

______

Describe the injury/occurrence*

(continue on back if necessary)

Why did the accident occur?

(continue on back if necessary)

Name of witnesse(s): ______Tel ext: ______

Any treatment given______

______

Will the employee be absent from work for more than 3 days? YES/NO*

Name of Head of Department: ______(ext) ______FURTHER TREATMENT (PLEASE TICK APPROPRIATE BOX) None [ ] Referred to Casualty [ ] Advised to see own GP [ ] Ambulance Service called [ ] Re-attend Health Centre [ ] ______PLEASE TICK APPROPRIATE BOX Academic & Related [ ] Trainee † [ ] Technician [ ] Secretarial & Clerical [ ] Child Visitor† [ ] Porter [ ] Postgrad/Postdoc [ ] Security [ ] Contractor [ ] Visitor [ ] Catering & Domestic [ ]

04/04/2018 24/63 Undergraduate student [ ] Maintenance [ ] † IMMEDIATELY TELEPHONE EXTENSION 13 7870, HUMAN RESOURCES: TRAINEES * PLEASE DELETE AS APPROPRIATE.

Describe the injury/occurrence*

Why did the accident occur?

04/04/2018 25/63 Appendix 2i

Local Rules: Charterhouse Square London EC1M 6BQ

2.i.1 Local Rules for the Use and Disposal of Radioactive Material at Charterhouse Square

2.i.1.1 Authorisation for registration of unsealed sources under section 1 of the RSA 93 at the i Charterhouse Square Site site

Radionuclides Maximum activity

3H 40 GBq

14C 20 GBq

125I 800 MBq

32P 200 MBq

51Cr 80 MBq Other 400 MBq / nuclides,  emitters 300 kBq

2.i.2 Authorisation for disposal of waste under section 6 of the RSA 60 for the Charterhouse site.

2.i.2.1Solid Waste

General.

Solid waste can be stored in the radioactive store in the lower basement John Vane. The key is available from the Safety Office, please ring x6036. Note: Animal carcasses or other biological waste cannot be accepted into the store. Maceration facilities are available in the BSU or CRUK John Vane building.

Low level waste (<110 kBq or 3Ci) All waste bags must be labelled with date and a reasonable estimate of total activity. Do not mix isotopes in the same bag.

(i) Very Low Level Waste

Local authority bins: > 400 kBq (10.8 Ci) per 0.1 m3 inactive waste (no one item to exceed 40 kBq) (1.08 Ci). All ‘radioactive’ stickers to be removed.

(ii) Higher Level Waste

Solid waste disposal via the Hospital.

Non-clinical solid waste may be disposed of via the hospital. This waste must not contain any alpha emitters and is limited to 2 GBq per year. This is approximately 37 MBq (1 mCi per week) for the whole site. The RPA must be told when disposals by this route are about to be made.

The procedures for this route of disposal are as follows:

Delivery to Store.

Telephone the Clinical Physics Group (Ext. 8292 or 8293) on Tuesday before 3 p.m. Give a) Lab Name b) Number of bags.

04/04/2018 26/63 c) Isotope in each bag. d) Activity of each (in MBq or kBq), decay -corrected to date of delivery.

An appoinment will be given for collection on Wednesday at the waste store in Middlesex Passage.

NB. Attach another label to the bag indicating delivery date and decay-corrected activity, or amend the existing label as necessary. On receipt, the waste will be double-bagged and re- labelled.

2.i.2.2 Liquid Waste

Other than immiscible organic liquids i.e. liquid scintillation, liquids may be disposed of via designated sinks.

The Departmental Radiation Protection Supervisor or the RPA must be contacted in all cases where there is doubt about the disposal of solid or liquid radioactive waste.

Authorised totals per month

3H, 14C + 35S 800 MBq (20 mCi) 32P 200 MBq (5 mCi) 125I 400 MBq (10 mCi) Other / 200 MBq (5 mCi)  200 Bq (5.4 nCi)

Contaminated animal carcasses should be disposed of in the BSU macerator.

The following rules apply:

1. The macerator may be used for the disposal of radioactive materials provided this route of waste disposal has been agreed with the RPA. All disposals of radioactive materials must be recorded in your bound source usage book.

2. Carcasses for maceration must be given to the BSU staff for disposal and users must follow the BSU rules for use of the macerator.

3. No metals or plastics should be macerated, e.g. no needles, plastic bags, rubber gloves, suture clips, paper or frozen materials.

4. A written declaration of the isotope and the amount of activity must accompany the waste given to the BSU staff.

2.i.2.3 Liquid Scintillation Waste

This must be disposed of by incineration via Grundon Ltd, - The safety office (X 6036) supervises collection of this waste. The waste is accumulated in yellow bins.

1. The waste must not be accumulated over a period longer than 365 days and the volume must not exceed 1200 litres.

a. Only tritium, 14C and 125I, may be disposed of in liquid scintillant. b. Plastic or glass vials containing scintillant may be accumulated in plastic bags inside suitable containers before removal to the scintillant waste store. c. At regular intervals these bags should be removed to the store and the total (estimated) activity recorded. These records must be available to the RPA.

The limits for disposal are as follows:-

Annual Limit

04/04/2018 27/63 3H 14C and 35S 120 MBq

32P 48 kBq

125I 1 MBq Any other isotope 120 kBq (except )

2.i.2.4 Gaseous Waste

No discharge other than tritium (not greater than 1 mCi/day).

Notes about waste:-

1. With due regard to its chemical and biological hazard radioactive waste should not be allowed to accumulate in an laboratory for more than two weeks unless special provision has been made for storage to reduce the activity by decay e.g. 32P or 125I (100 days).

2. Waste only becomes waste when it is declared to be so.

3. (Radioactive animal carcasses must be disposed as liquid waste via the macerator in the BSU.

4. Radioactive solid waste in the form of 'sharps' (hypodermic needles, Pasteur pipettes, broken glass, etc.) must be sealed in 'sharps' containers. This material must be disposed of via the non- radioactive 'sharps' route and must therefore conform to the criteria for low level solid radioactive waste. Storage for decay may be necessary. This latter restriction must be observed for isotopes of iodine.

5. Radioactive liquid waste EXCLUDING liquid scintillant and organic solvents must be discharged into the drainage system via designated sinks.

6. Only designated sinks should be used for the disposal of radioactive waste.

7. Adequate dilution of the waste with running tap water must be ensured.

8. Suitable forms for recording the disposals of liquid waste must be available near the designated sinks and USED.

2.l.2.5

CONTACTS:-

Radiation Protection Adviser (RPA) Dr J Horrocks 0207 601 8291 College Safety Adviser Dr J Robinson 0207 882 5431 Assistant Safety Adviser Anne Harris 0207 882 6036 Appointed Doctor Dr J Spencer 0207 882 3176

Contact for film dosimetry Dr J Horrocks 0207 601 8291

Radiation Protection Supervisors at Charterhouse Square

Biochem Pharmacology Fulvio D’Acquisto 882 5754 [email protected] Biological Services Unit Richard Thomson* BJRU Panos Kabouridis 882 5664 [email protected] Mol Endocrinology Jackie Burrin 8826248 [email protected] Cardiac Vasc.& Inflamm Ivana Vojnovic 882 6087 [email protected] Experimental Therapeutics Delphine Lees 882 6013 [email protected] Experimental Therapeutics Noorafza Khan 882 5650 [email protected]

*The Biological Services Unit [or Animal House] is occasionally host to research using radioactive materials.

04/04/2018 28/63 04/04/2018 29/63 Appendix 2j

Local Rules: West Smithfield

2.j.1 Authorisation for registration of unsealed sources under section 1 of the RSA 93 on this site

Radionuclide Maximum activity

99Mo generator 8 GBq

225Ac generator 2 GBq

131I 10 GBq

3H 3 GBq

14C 500 MBq

125I 5 GBq

32P 2 GBq

45Ca 1 GBq

90Y 5 GBq 201Tl 1 GBq 35S 2 GBq Other 2 GBq / nuclides,

2.j.2 Waste Management

Authorisation limits for disposal of waste under section 6 of the RSA 60 for the West Smithfield site and procedures.

2.j.2.1Solid Waste

Local authority bins: > 400 kBq (10.8 Ci) per 0.1 m3 inactive waste (no one item to exceed 40 kBq) (1.08 Ci). No 'radioactive' stickers to be used. Accumulated for no longer than 14 days

Note: Solid waste should be stored for decay but may be transferred to the Trust for accumulation before disposal (maximum accumulation time is 600 days) Maximum amounts which may be accumulated are:

tritium/carbon-14 400 MBq 125I/131I 5 GBq any other radionuclide except alpha 3 GBq

Disposal procedures

(a) Solid waste must be accumulated in red plastic bags containing the radiation warning label. If at all possible each waste bag should contain less than 1 MBq – if the bag contains activity in excess of 4 MBq a heavy duty bag should be used.. (b) Each bag should be no more than 2/3 full and be securely sealed with tape bearing the radiation warning label. (c) Each bag must have a completed Solid Waste Data Sheet attached to it. The Data sheet should be attached using tape bearing the radiation warning label. The sheet should contain; department name,

04/04/2018 30/63 contact name and telephone number, radionuclide, activity and date. Data sheets are available from the Clinical Physics Department. (d) Separate tags should be used for different radionuclides. (e) Radioactive “sharps” must be disposed of in the appropriate protective container. (f) Radioactive animal carcasses (thawed) must be disposed of via the macerator after arrangements with the College BSU. (g) No liquids may be disposed of as solid waste.

2.j.2.2Liquid Waste

Accumulation of liquid waste

Liquid waste should be disposed of as soon as reasonably practicable but 125I waste (2 GBq) may be accumulated for no more than 600 days.

Disposal

Aqueous liquids but not other than immiscible organic liquids i.e. liquid scintillation, may be disposed of via designated sinks.

3H 1 GBq

14C 500 MBq technetium 99m 10 GBq

32P 500 MBq

125I / 131I (total) 10 GBq 35S 500 MBq Any other radionuclide 500 MBq (except an alpha emitter)

2.j.2.3Liquid Scintillation Waste

This must be disposed of transfer to The Trust for incineration. The waste must not be accumulated over a period longer than 100 days and the volume must not exceed 3 m3. The limits for radionuclides in the accumulated waste are:

Any radionuclide except alpha 200 MBq

Annual Limits

3H, 14C,32P,35S,45Ca 500 MBq in total

Any other 1 MBq radionuclides

Disposal Procedures (a) Plastic vials containing organic liquid scintillant must be accumulated in heavy duty plastic Jencons bags bearing the radiation symbol. The vials must be securely stoppered. Prior to disposal the waste should be double bagged with an additional Jencons bag. (b) Each bag should be no more than 2/3 full and securely sealed with tape bearing the radiation symbol.

04/04/2018 31/63 (c) A completed Scintillation Waste Disposal Sheet should be attached to each bag. This sheet should include; departmental name, name and contact telephone number, radionuclide, activity and date. Data sheets are available from the Clinical Physics Department.

2.j.2.4 The Radioactive Waste Store The radioactive waste store is in Middlesex Passage.

(a) Routine collection of waste at the store is made on Wednesday mornings – an appointment must be made with the Radiation Safety Section.

(b) Radioactive waste should be brought to the store by laboratory staff.

2.j.2.5General notes about waste:- (1) With due regard to its chemical and biological hazard radioactive waste should not be allowed to accumulate in an laboratory for more than two weeks unless special provision has been made for storage to reduce the activity by decay e.g. 32P or 125I (100 days). (2) Waste only becomes waste when it is declared to be so. (3) Radioactive animal carcasses must be disposed as liquid waste via the macerator in the BSU. (4) Radioactive solid waste in the form of 'sharps' (hypodermic needles, Pasteur pipettes, broken glass, etc.) must be sealed in 'sharps' containers. This material must be disposed of via the non-radioactive 'sharps' route and must therefore conform to the criteria for low level solid radioactive waste. Storage for decay may be necessary. This latter restriction must be observed for isotopes of iodine. (5) Radioactive liquid waste EXCLUDING liquid scintillant and organic solvents should be discharged into the drainage system via designated sinks. (6) Sinks designated for the disposal of radioactive waste should be identified with a warning notice. (7) Adequate dilution of the waste with running tap water must be ensured. (8) Suitable forms for recording the disposals of liquid waste must be available near the designated sinks and USED. (9) Liquids as scintillant. (a) Only tritium, 14C, 35S, 32P and 45Ca may be disposed of in liquid scintillant. (b) Plastic or glass vials containing scintillant may be accumulated in plastic bags inside metal containers before removal to the scintillant waste store. (c) At regular intervals these bags should be removed to the store and the total (estimated) activity recorded. These records must be available to the RPA.

2.j.2.6CONTACTS:-

Radiation Protection Adviser (RPA) Dr J Horrocks 0207 601 8291 College Safety Adviser Dr J Robinson 0207 882 5431 Appointed Doctor Dr J Spencer 0207 882 3176

The Royal Hospitals Trust RPA and contact for film dosimeters Dr J Horrocks 0207 601 8291

04/04/2018 32/63 Appendix 2k Local Rules: Whitechapel E1 2AD

1 INTRODUCTION These Local Rules are issued under the Ionising Radiations Regulations 1999 (IRR99) and Approved Code of Practice and are the means of complying with these Regulations for staff working in the laboratory. The Head of the Institute, Heads of Departments (Centre Leads), Radiation Protection Supervisor Manager (RPM) and Radiation Protection Supervisors (RPS) must also be aware of the Radiation Safety Policy.

Date of Local Rules April 2006 (amended)

Name of Laboratory Start 2/3 Radiation Laboratory Location of Laboratory LG 118/119 Radionuclides (updated Jan 2006) 125I (30 keV gamma) Max. activity: 37 MBq 32P Max. activity: 18.5 MBq 3 Max. activity: H (18 keV max) 370 MBq 14C Max. activity 18.5 MBq 35S Max. activity 158 MBq 33P Max. activity 27.8 MBq X-ray generating equipment None Employer QMUL Name of Institute Cell and Molecular Science Head of Institute Professor MA Curtis x13 2300 RPS Manager (RPM) Dr. Greg Michael X13 2297 Radiation Protection Supervisors (RPS) Cutaneous Research x13 2346 Head of Centre Dr.Mohammed Ikram Prof. I.M.Leigh Diabetes, Metab.Med. Dr.Mohammed Hawa X13 2365 Prof G.A.Hitman Gastroenterology Martine Barel x13 7225 Prof. I.R.Sanderson Haematology Paul Allen x13 2279 Prof. F.Cotter Infectious disease Jose Aduse-Opoku x13 2320 Prof. M.A.Curtis Neuroscience Dr.Greg Michael x13 2297 Prof. J. V. Priestley Oral Biology Mr. Steve Cannon x13 7136 Prof. F. Fortune Surgery Dr. Tom Going x13 3002 Prof N. Williams Radiation Protection Adviser (RPA) Dr. Julie Horrocks, Clinical Physics Group, x15-8291 St. Bartholomew's Hospital Health and Safety Office Dr. John Robinson- Advisor x13 5431 Ms. Anne Harris- Assistant Advisor (CHS) x15 6036 Mr. Alan Scott- Deputy Advisor (Mile End) x13 3009 2 DESIGNATION OF AREAS

Area to which these Local Rules apply Start 2/3 Radiation Lab LG 118/119 Designated Controlled Area(s) East Bay of Rad. Lab. LG119 Designated Supervised Area(s) West Bay of Rad. Lab LG 118  Signs indicating designation of the areas are prominently posted on all doors to the laboratory

04/04/2018 33/63 3 DESIGNATION OF STAFF AND PERSONAL MONITORING  There are no classified persons in the laboratory.  All staff working with radiation in the laboratory must wear any personal dosemeters issued.  Whole body dosemeter must be worn on the outside of the laboratory coat at waist level, with the personal identification number facing out.  Extremity dosemeter(s) must be worn on the finger(s) most exposed to radiation, at the fingertip.  Dosemeters are personal and must not be shared with other workers.  When not in use, they must be kept in a radiation-free area, away from sources of heat and moisture.  Dose records, which must be kept for two years, must confirm that no worker is likely to exceed three tenths of any dose limit.

4 DOSE INVESTIGATION LEVEL  A formal investigation must be carried out by the RPA if the annual effective dose exceeds 4 mSv.  An investigation card will be sent to the RPS if a member of staff exceeds the monthly reporting level.

Employees 18 years of age or above Annual Dose Limit (IRR99) Monthly Reporting Level Whole body (Effective dose) 20 mSv 0.33 mSv Skin (averaged over 1 cm² of exposure) 500 mSv 4.2 mSv Hands, Forearms, Feet and Ankles 500 mSv 4.2 mSv

5 PREGNANCY AND BREAST-FEEDING  Pregnant workers must inform the RPS and RPA as soon as the pregnancy is known in order to determine whether any change in working conditions is required.  Workers who intend to breast-feed must also inform the RPS and RPA as soon as possible.

6 ENTRY INTO DESIGNATED AREAS

Requirements for entering designated area(s)

Entrance  Only the south door fitted with a chamber code lock will be used for entry and exit  Radiation workers will be given the code to this door and should not disseminate the code to other staff unless permission has been obtained from the RPM  Other doors will remain bolted shut unless prior approval of the RPM has been obtained or in emergency Radiation Workers  Only authorised workers whose names are on the list of authorised workers in the Radiation Protection Folder can work in the designated area(s)  Must be trained in correct handling techniques  Must have read the local rules and signed declaration to this effect  Must wear any whole body dosemeter and extremity dosemeter(s) issued Trainees  Must have obtained the permission of the RPS  Must have read Local Rules and agreed to abide by them  Must wear any whole body dosemeter and extremity dosemeter(s) issued Engineers, maintenance  Must have made prior arrangements with RPS staff, physicists and

04/04/2018 34/63 inspectors  Must not touch or remove anything having the trefoil radiation warning sign without asking RPS Other staff in department As above Visitors and staff from As above other departments Cleaning Staff  Must ask member of staff before entering the designated area(s)  Can work in supervised areas but not Controlled Area(s) unless asked by the RPS to do so  Must not touch anything marked with the trefoil radiation warning sign  Must not remove any waste bags that have the trefoil radiation warning sign on them

7 WORKING PROCEDURES WITH RADIATION

A. Display of Environment Agency documents The following documents issued by the Environment Agency must be displayed prominently in the designated areas, together with these Local Rules: 1. Registration to hold radioactive substances 2. Authorisation to accumulate and dispose of radioactive substances 3. Names of RPS and RPM supervising waste accumulation and disposal

B. At the start of each work session 1. The radiation laboratory is a multi-user facility. At each isotope work area there is a log book in which users must record their use of that area. Please also note equipment used outside the area. 2. Monitoring of use areas and equipment must be performed before use (see Monitoring below; section H) and the results recorded in the log book.

C. Protective clothing

1. Dark blue laboratory coats must be worn in the laboratory area at all times. These can be obtained from the laundry store. 2. After use, blue laboratory coats must be checked for contamination and removed before leaving the laboratory. Hang clean coats in the designated area of the laboratory near the entrance. 3. Laboratory coats must be changed regularly. Contaminated laboratory coats must not be worn. If coats are found to be contaminated, do not put in the laundry. If the contamination can be removed safely by washing at the sink, then this may be attempted. If significant contamination has occurred it may be necessary to store the article until the detected radiation has decreased (if practical) or dispose of it via radioactive waste. 4. Safety glasses or face shields must be worn when doing laboratory work. 5. Disposable gloves must be worn when doing laboratory work. Gloves should be changed frequently. Two pairs of gloves must be worn while dispensing from vials containing high activities, discard the outer pair when the operation is completed. 6. Overshoes must be worn in high activity areas or where the floor has been contaminated. 7. Plastic apron should be worn in high activity areas or when dealing a major spill.

D. Personal safety 1. All persons using unsealed radionuclides have a duty to protect themselves and others from radiation hazards arising from their work. 2. Never work with unprotected cuts or breaks in the skin, particularly on the hands or forearms. 3. Eating, drinking, smoking or applying of cosmetics in the laboratory are forbidden. 4. Food, drink, cigarettes, crockery and cutlery must not be brought into the laboratory. 5. No mouth-operated equipment is allowed to be used. 6. Use paper handkerchiefs, instead of fabric handkerchiefs, and dispose of them appropriately.

04/04/2018 35/63 7. While wearing gloves, avoid touching skin surfaces, eyes, hair and clothes. 8. A fire extinguisher and first box are kept opposite the entrance to the laboratory. In the case of an accident, as required in all other laboratories, report forms must be filed as directed by the Health and Safety Office of the College.

E. General rules for safe working practice 1. All radiation exposures must be kept as low as reasonably practicable. 2. Plan carefully and use the minimum quantity of radioactivity needed for the investigation to minimize exposure and waste generation. 3. Procedures must minimize: a. the deposition of radionuclides in body tissues, b. skin contamination and spread of contamination, c. the production of airborne radioactivity (aerosols, radioactive dust) and d. the effects of external radiation. 4. Always work carefully and tidily. 5. Do not hold unshielded radioactive sources in the hand, whether solid or containing liquid. Use a stand or holder or shielding. 6. Plan ahead and get everything ready for the session before starting work with radioactivity. 7. Tubes and containers of radioactive liquid must be kept stoppered to avoid spills where possible. 8. All containers holding radioisotopes must be clearly labelled "radioactive" e.g. using the appropriate warning tape and labelled with the following details: a. name of the radioisotope b. batch number of the stock vial if applicable c. activity at a specified time and date d. volume e. name and contact details of the person who prepared the sample or aliquot. 9. Do not use radiation warning tape for non-warning purposes. 10. Procedures for carrying out all radioactive work are written down in the standard operating procedures (SOP) which must be followed at all times. 11. Use an appropriate, calibrated radiation contamination monitor to regularly check for personal and laboratory contamination (see Contamination monitoring and decontamination section). 12. External radiation dose must be kept to a minimum. The following principles should be adopted: a. Minimise exposure time, e.g. return stock vial to a place of safe storage as soon as possible. b. Maximise distance from radioactive source, e.g. use sample holders and hold at arm's length where possible. c. Utilise appropriate shielding and work behind shields where necessary: lead shielding for gamma emitters and Perspex for beta emitters. If in any doubt about what is appropriate shielding, seek the advice of the RPA. 13. The activities of any solid or liquid radioactive waste generated during a procedure must be recorded and the waste disposed of appropriately (see Waste section). 14. Report to the RPS any incident that is related to radiation safety.

F. Minimizing contamination 1. Radioactive work must be contained to minimise contamination. Radioactive work can only be carried out in trays lined with absorbent material, on the benches within designated area. Designated benches and trays are clearly marked with the isotope which will be used in the particular area. Radioactive work in non-designated trays, benches and areas is not allowed. 2. No radioactive work is permitted outside of the Radiation Laboratory LG118. Prepared samples (dried gels, tissues prepared for autoradiography, etc…) may be processed in the dark rooms if danger of contamination is assessed and minimised. 3. Keep active and non-active work segregated as far as possible. 4. Contamination must be kept as low as reasonably achievable. 5. Take care to avoid drips and splashes.

04/04/2018 36/63 6. Do not rinse narrow-necked tubes or containers by holding them under the tap, instead, wash by adding rinse water from a wash bottle or by using a pipette. 7. Any spillage must be cleaned up immediately (see Contingency section). 8. If gloves are suspected to be contaminated check using an appropriate monitor and remove as necessary. Do not handle instruments, switches, handles, stationary when wearing gloves before checking for contamination. The computer to be located in the West laboratory should not be used with gloved hands. 9. Monitor (see section H below) gloves and benches continuously during work with radioactivity. If contamination is detected on gloves remove immediately and put on a new pair. Take care to determine, through monitoring, if other surfaces touched may be contaminated. Decontaminate as necessary. Record all results.

G. End of each work session At the end of each work session, each worker must: 1. Tidy the work space and put things (stock, samples, equipment) away in their proper places. 2. Ensure that all radioactive sources (clearly labelled) are stored in secure locations and the possibility of loss or damage minimized by appropriate containment and security. 3. Record all wastes generated and dispose of them appropriately (see Waste section). 4. Wash gloved hands then remove gloves and dispose of them appropriately. 5. Wash hands thoroughly with soap and water in the hand basin. 6. Monitor hands, laboratory coat and shoes with a contamination monitor calibrated for the isotopes used. 7. Monitor the work area. 8. Record personal and environmental monitoring results in the log book or monitoring record sheets as appropriate.

H. Contamination monitoring and decontamination 1. Use a radiation contamination monitor that is appropriate for the radionuclide (see below). It must be calibrated annually. 2. Monitor the work area systematically for radioactive contamination, including the areas surrounding the radioactive waste bin, radioactive waste sink and hand basin. 3. An item or area would be deemed contaminated if the surface contamination limit for the radionuclide concerned is exceeded. 4. Contamination must be removed as soon as possible. The calibrated count rate and surface contamination limit are normally labelled on the monitor or recorded in the calibration certificate. Always check these figures before using the monitor. 5. The following count rate above background at 3mm above the surface can be used as a rough guide.

Radionuclide Mini EP15/EL (cap off) Mini 44A/44B Berthold LB 1210 3H ( ) Perform wipe tests using liquid scintillation techniques 14C ( ) 40 cps (30 Bq cm-2) Not suitable 10 cps (3 Bq cm-2) 32P ( ), 33P ( ) 15 cps (3 Bq cm-2) Not suitable 90 cps (3 Bq cm-2) 35S ( ) 40 cps (30 Bq cm-2) Not suitable 10 cps (3 Bq cm-2) 99mTc ( ) Not suitable 100 cps (30 Bq cm-2) 70 cps (30 Bq cm-2) 125I ( ) Not suitable 15 cps (3 Bq cm-2) 15 cps (3 Bq cm-2)

6. If any contamination is found on the hands - wash the hands several times with soap and running warm water in the designated waste sink and re-monitor the hands until contamination has been removed. If the contamination cannot be removed by simple washing, inform the RPS and seek advice from the RPA. 7. If any contamination is found on removable items such as books, stationery, clothing and personal items – decontaminate by simple wiping and cleaning where possible. If contamination persists, a. remove item and store in Jencons plastic bag with trefoil radiation warning symbol

04/04/2018 37/63 b. mark bag with name of radionuclide, date, time and owner’s name c. store bag under RPS’s direction until radioactivity has decayed to background d. send washable items to laundry 8. If any contamination is found anywhere else – see Contingency section 9. If contamination has occurred, the count rate before and after decontamination should be recorded in the log book or monitoring record sheets when available, together with the time of monitoring.

8 RADIOACTIVE STOCK 1. Stock can only be ordered by authorised workers, with the knowledge of the RPS and authorisation prior to ordering from the RPM. 2. Radioactive products must be delivered in care of the RPM. The porter in Start 2/3 has been requested to contact the RPM (or deputised RPS representative if unavailable) to arrange pick up from the delivery room. A separate log book for radioactive orders is held in this room and must be signed when products are received into the delivery room with the delivery code number. This book must also be signed when orders are taken from the room for storage in the laboratory. Orders must be delivered during working hours. The porter is available from 8am-4pm. 3. Total stock (stock to be ordered and existing stock) must be within the internal authorisation limit set by Radiation Safety in conjunction with the department. Anything (isotope, chemical form or activity) outside the internal authorisation must not be ordered without the prior consent of the RPM who will act in consultation with the RPA. 4. All stock materials must be clearly marked "radioactive" e.g. using a sticker with a trefoil radiation warning symbol or appropriate warning tape and labelled with the relevant details (see section on General rules for safe working practice). 5. Receipt of stock must be signed in and the record of stock in the laboratory updated with the correct batch number, product type and the activity at a specified time and date. These records will be maintained through the Isostock system which is accessible on line in the radiation laboratory via the computer. 6. All stock must be stoppered and kept in a refrigerator or freezer designated for radioactive holdings. Stock that comes with shielding material must be kept within this shielding material. The refrigerator or freezer must have a trefoil radiation warning sign on the front and must not be used for storing food or drink. 7. All stock must be accounted for.

9 RADIOACTIVE WASTE 1. Radioactive waste material should be kept to a minimum. Non-radioactive solid waste should not be disposed of as radioactive waste. 2. All materials containing radioactivity or items containing the radioactive trefoil warning symbol that cannot be defaced must be disposed of as radioactive waste. They must NOT be disposed of as clinical waste or office waste.

04/04/2018 38/63 Type of radioactive waste Appropriate storage and disposal Liquid non-scintillant containing waste  Designated radioactive waste sink followed by copious amounts of water  Sink must be clearly marked with a trefoil radiation warning symbol Solid non-scintillant containing waste  Gamma emitters < 50keV: Stainless steel waste bin with stainless steel lid (no glass or sharps)  Gamma emitters > 50keV: Lead-lined waste bin with lead-lined lid  Beta emitters: 1cm thick Perspex bin with 1cm thick Perspex lid  One bin for each radionuclide. Bin must be marked with name of radionuclide and have trefoil radiation warning symbol.  Waste bin must be lined with a clear Jencons plastic bag with trefoil radiation warning symbol.  Record the start date of the Jencons bag.  When two-thirds full, seal bag and record the close date (date, month and year) of the bag and the total activity. Glass or sharps (non-scintillant)  Shielded radioactive sharps bin with trefoil warning symbol. contaminated with radioactivity  Record the start date of the sharps bin.  Seal bin when two-thirds full and record the close date (date, month and year) and the total activity Scintillant waste (solid, liquid and  Designated plastic sealable scintillant bin with trefoil warning symbol. sharps)  Label bin with name of radionuclide.  Record the start date of the scintillant bin.  Seal bin when two-thirds full and record the close date (date, month and year) and the total activity. Biological samples / tissues  Consult the RPA

3. The sealed waste bags, sharps bins etc. must be stored securely in a designated locked radioactive waste storage area/cupboard that is appropriately shielded until disposal via an authorised route. 4. Radioactive waste bags or bins should be taken from the laboratory weekly or fortnightly by authorised workers in the laboratory coordinated by the RPM to the Trust waste store at pre-booked times. A transfer note must be completed for each bag/bin. 5. All radioactive waste bags, sharps bins and containers must be properly accounted for and reflected in the records. They must by no means “disappear” or be removed with clinical waste or office waste. 6. Any item that cannot be accounted for must be notified to the RPS and RPM immediately. Also contact immediately the College Health and Safety Office (x15-6036 Ms. Anne Harris, x13-5431 Dr. John Robinson) and the Trust Radioisotopes Dept. at Whitechapel 14-7454 or 14-3285 (Dr. Margaret Newell). (see Contingency Section – Loss of radioactive material).

10 INTENTION TO START NEW PROCEDURE, PROJECT OR FACILITIES 1. The radiological protection aspects of any new procedure, project or facilities that are intended must be discussed with the RPM and RPA before being carried out. 2. Always do a dummy run without radioactivity to check new procedures.

11 CESSATION OF RADIOACTIVE WORK 1. Inform RPM of intention to stop radioactive work who will then inform the RPA. 2. Any designated radioactive work bench, area, room or laboratory that is no longer going to be used for radioactive work must be decommissioned. 3. Remove and properly dispose of radioactive materials from the area as well as from equipment, refrigerator or freezer that has been used for radioactive work– radioactive sources (including those enclosed within equipment), samples, stock, waste and containers like lead pots. 4. Make a record of where the removed radioactive sources, samples, stock and waste have gone. 5. Remove and deface all radiation warning signs and symbols. 6. Properly and systematically monitor the whole area, including equipment, sink, hand basin, furniture and floor for contamination and decontaminate. 7. Contact the RPA for a decommissioning survey before using the area for non-radioactive work or before vacating the place.

04/04/2018 39/63 12 TRANSPORT OR SHIPMENT OF RADIOACTIVE SUBSTANCES  If radioactive substances need to be transported or shipped to a different site, contact the RPA.

13 CONTINGENCY Try to remain calm and not panic.

A. Loss of radioactive material 1. Loss of any radioactive material is a very serious matter, whether it is a radioactive source, sample, stock vial or a radioactive waste item or bag. Notify the RPS, RPM, and RPA and Health and Safety Office (tel. numbers on page 1) 2. Report all relevant details. 3. The RPM/ RPA must contact the Environment Agency without delay if the item is not located. 4. Record the incident in the incident record as soon as possible while the memory is relatively fresh. 5. Assist the RPA/RPM during investigation of incident.

B. Minor Spill / Event:  Spillages less than 5 MBq for gamma emitters and less than 0.2 MBq for beta emitters

1. If there is someone working near where the spill has occurred, verbally warn that a spill has occurred. 2. Isolate the area to prevent unnecessary spread and personnel exposure. 3. Wear two pairs of disposable gloves and laboratory coat. Wear overshoes and plastic apron if necessary. 4. Contain the spill. Cover with absorbent paper. 5. Using appropriate, calibrated monitoring equipment, evaluate the presence of contamination on an individual’s skin, clothing, laboratory equipment and floor. If skin, eye or clothing contamination is present, contact the RPS immediately. 6. Use swabs/wipes to clear up the spill – clean with repeated actions from the edge of the spill to the centre of the spill to avoid the spread of contamination. Dispose of swabs/wipes in an appropriate, designated radioactive waste container. Use tongs if necessary. 7. Survey the area of the spill to determine the extent. 8. Decontaminate the affected area using decontaminant detergent and re-survey. Change outer pair of gloves and overshoes as and when necessary. 9. Continue from step 6 until activity drops to below the action level for surface contamination. 10. Record the occurrence of a spill in the environmental monitoring record sheet, quoting maximum counts per second reached and final counts per second after decontamination is complete. Record the time against the count rate. 11. Continue with work. 12. Carry out personal and environmental monitoring at the end of the work session and record results as per normal working procedures.

C. Major Spill / Event:  Spillages greater than 5 MBq for gamma emitters and greater than 0.2 MBq for beta emitters  Cuts in the skin, contamination in the skin or eye  Large area contamination or any situation where contamination may have been spread outside the authorised area  Release of airborne radioactivity

1. Verbally notify all persons in the area that a major spill/event has occurred and evacuate unnecessary and uncontaminated personnel. 2. Seal off the area using radioactive warning tape and warning notices. Notify the RPS and RPM. Notify the RPS, RPM and H&S Office (tel. numbers on page 1) Contact the RPA. Give as much of the following information as possible to the RPA: i. Radionuclide involved ii. Amount of radioactivity

04/04/2018 40/63 iii. Chemical form of released material, other hazardous chemicals involved iv. Volume spilt or released v. Exact location of incident (street, building, floor, room number) vi. Persons contaminated or exposed, estimate of amount (e.g. estimated activity or 2000 counts per second 32P, 10 cm² on skin of forearm) vii. Any injuries, what they are, how serious viii. Airborne radioactivity possibly present or not ix. Time of incident x. How did it happen xi. What you have done so far xii. Names of RPS and Head of Department xiii. Name of person reporting and job position xiv. Telephone number where you can be reached

Dealing with personal injury or personal decontamination : 3. Deal with injured or contaminated person(s) as a matter of priority and leave area decontamination till help is available from other competent staff. a. Check if any persons have been injured, e.g. cuts or needle stick injury. b. Check if any persons have been contaminated by monitoring all over the body using an appropriate, calibrated contamination monitor. Note initial count rate and time. 4. If contaminated, start decontamination straight away. Ask the person to remove all contaminated clothing and shoes. Give clean clothing to wear. Put contaminated items in a plastic bag. 5. If there is injury and contamination, wash with copious amounts of warm running water. If possible, ask the affected individual to wear two pairs of gloves and do the washing himself or herself. Do not use a brush or any abrasive material on the skin. Encourage bleeding if the skin has been cut. 6. Supervise this washing. The person doing the supervision should wear full protective clothing – plastic apron, two pairs of gloves and overshoes. 7. Ask the affected individual to wash downwards towards extremities, not upwards. Avoid running contaminated water or fluid over other parts of the body. Avoid spreading contamination to other areas if possible. Washing with copious amount of running water should remove most of the contamination from the person under normal circumstances. 8. Change outer pair of gloves frequently. 9. Use running water and do not soak limb(s) in unchanging water. 10. Continue to wash the contaminated body part under running water. Alternate wash with monitoring until person is sufficiently decontaminated or until a medical physicist has arrived. Note count rate and time at each monitoring where possible. 11. Use paper towels for drying and put waste in plastic bag and treat as radioactive waste. 12. Uncontaminated or sufficiently decontaminated wounds can be dressed if appropriate. 13. More serious injury (including needle stick injuries) should be referred to the Accident & Emergency Department. However, any radioactivity has to be contained. 14. If the person is contaminated but there is no injury, soap can be used as well as warm running water.

Area decontamination: 15. If possible, prevent the spreading of the radioactive material by using absorbent paper. Do not attempt to clean it up. Confine all potentially contaminated individuals in order to prevent spread of contamination. 16. If possible, shield the source (lead for gamma emitters and Perspex for beta emitters), but only if it can be done without significantly increasing your radiation exposure. 17. Leave the affected room and lock the doors to prevent entry. Avoid as much as possible further contamination and spread of radioactive materials to unrestricted areas such as corridors and non- radiation areas. If the incident happens in an unrestricted area such as a corridor, instruct people to move away and cordon off 2 metres from the locale of the incident using radioactive warning tape and warning notices. 18. Remove all gloves, contaminated clothing and footwear, and place in a clear plastic bag. Mark bag as radioactive and label bag with details of the radionuclide, date, time and owner’s name. Await instructions concerning clean-up from the Radiation Safety Physicist.

04/04/2018 41/63 19. At the end of the incident, the RPS and the person(s) concerned will have to fill in the Trust Incident Form. One copy should be kept in the Radiation Protection Folder and one copy should be sent to the RPA.

Local Rules written by: Position:

Signature:

Approved and signed by RPA:

04/04/2018 42/63 Appendix 2 l

Local Rules: Mile End E1 4NS

2.l.1 Local Rules for the Use and Disposal of Radioactive Material at Mile End

2.l.1 Authorisation for registration of unsealed sources under section 1 of the RSA 93 at the Mile End campus

Radionuclide Maximum activity

3H 185 GBq

14C 370 MBq

125I 740 MBq

32P 740 MBq 35S 740 MBq Other 740 MBq / nuclides,

2.l.2 Authorisation limits for disposal of waste under section 6 of the RSA 60 for the Mile End site and procedures.

2.l.2.1Solid Waste

Local authority bins: > 400 kBq (10.8 Ci) per 0.1 m3 inactive waste (no one item to exceed 40 kBq) (1.08 Ci). For the sum total of tritium and carbon-14 the concentration is 4 MBq per 0.1 m3 inactive waste and no one item to exceed 400 kBq. N.B No 'radioactive' stickers to be used.

Note: Solid waste should be stored or accumulated for decay subject to a maximum accumulation time of 800 days and a maximum volume of 5 m3. Maximum amounts which may be accumulated are:

Any radionuclide (except alpha emitters) 60 MBq

(iii) Disposal procedures

1. Solid waste must be accumulated in clear plastic bags containing the radiation warning label. 2. Each bag should be no more than 2/3 full and be securely sealed with tape bearing the radiation warning label. 3. Each bag must have a completed Solid Waste Data Sheet attached to it. The Data sheet should be attached using tape bearing the radiation warning label. The sheet should contain; department name, contact name and telephone number, radionuclide, activity and date. Data sheets are available from the RPS. 4. Separate tags should be used for different radionuclides. 5. Radioactive “sharps” must be disposed of in the appropriate protective container. 6. Radioactive animal carcasses (thawed) must be disposed of via the macerator after arrangements with the College BSU. 7. No liquids may be disposed of as solid waste.

2.l.2.2Liquid Waste

Accumulation of liquid waste Liquid waste may not be accumulated.

04/04/2018 43/63 Disposal

Other than immiscible organic liquids i.e. liquid scintillation, liquids may be disposed of via designated sinks.

3H and 14C 4 GBq

125I 80 GBq Any other radionuclide 200 MBq (except an alpha emitter)

2.l.2.3Liquid Scintillation Waste

This must be disposed of by transfer to a specialist contractor. The waste must not be accumulated over a period longer than 800 days and the volume must not exceed 5 m3. The limits for radionuclides in the accumulated waste are:

Any radionuclide except alpha (in total) 1 GBq

Annual Limits Shanks Chemical Services – Any other radionuclide (except an alpha emitter) 1GBq White Rose Environmental – carbon-14 and tritium 300 MBq Any other radionuclide (except an alpha emitter) 100 MBq

(i) Disposal Procedures 1. Plastic vials containing organic liquid scintillant must be accumulated in heavy duty plastic drums bearing the radiation symbol and the Isotope Accumulation code. The vials must be securely stoppered.

2. A completed Scintillation Waste Disposal Sheet should be attached to each bag. This sheet should include; departmental name, name and contact telephone number, radionuclide, activity and date. Data sheets are available from the RPS

(ii) The Radioactive Waste Store Transfer to the store is by arrangement with the RPS.

2.l.2.4General notes about waste

1. With due regard to its chemical and biological hazard radioactive waste should not be allowed to accumulate in an laboratory for more than two weeks unless special provision has been made for storage to reduce the activity by decay e.g.32P or 125 I (100 days). 2. Waste only becomes waste when it is declared to be so. 3. Radioactive animal carcasses must be disposed as liquid waste via the macerator in the BSU. 4. Radioactive solid waste in the form of 'sharps' (hypodermic needles, Pasteur pipettes, broken glass, etc.) must be sealed in 'sharps' containers. This material must be disposed of via the non- radioactive 'sharps' route and must therefore conform to the criteria for low level solid radioactive waste. Storage for decay may be necessary. This latter restriction must be observed for isotopes of iodine. 5. Radioactive liquid waste EXCLUDING liquid scintillant and organic solvents should be discharged into the drainage system via designated sinks. 6. Sinks designated for the disposal of radioactive waste should be identified with a warning notice. 7. Adequate dilution of the waste with running tap water must be ensured. 8. Record liquid disposals in the log book. 9. Liquids as scintillant. (a) Plastic or glass vials containing scintillant may be accumulated in drums before removal to the scintillant waste store.

04/04/2018 44/63 (c) At regular intervals these drums should be removed to the store and the total (estimated) activity recorded. These records must be available to the RPA.

2.l.2.5CONTACTS:-

Radiation Protection Adviser (RPA) Julie Horrocks 0207 601 8291 Site Radiation Protection Officer Alan Scott 0207 882 3009 College Safety Adviser John Robinson 0207 882 5431

The Royal Hospitals Trust RPA and contact for film dosimeters Julie Horrocks 0207 601 8291

04/04/2018 45/63 Queen Mary University of London

Project Registration and Approval for Use of Radioactive Substances (Open or Unsealed Sources)

Please return this form and a copy of the experimental protocol to Health and Safety, Queen’s Building, Mile End E1 4NS.

N.B. All sections of this form must be completed before project approval will be given.

For Office use only Project approval date ……/……../20…..

Project Project review date .…../…….../20….. Number Project reapplication date ……/…….../20….

Are the following attached:

Experimental protocol Y/N Laboratory plan Y/N

Section 1 The Project

Project Title:

Location of work; (tick box as appropriate) Mile End Whitechapel Charterhouse Square West Smithfield Other

Department / Centre and Institute

04/04/2018 46/63 Personnel involved

Head of Department/Institute

Telephone number

e-mail address

Centre & Institute / Department

Project Supervisor

Telephone number

e-mail address

Radiation Protection Supervisor

Telephone number

e-mail address

Date of RPS training

Name of ARSAC licence holder (if radionuclides are administered to patients or volunteers)

Telephone number

e-mail address

04/04/2018 47/63 Personnel working on the project

Name Academic/Technician/ Radiation Date attended Signed Post-doc/PhD Safety declaration that student/Other Course local rules read Attended and understood Y/N Y/N

04/04/2018 48/63 Section 2 Radioactive Materials (Open or unsealed sources)

Information Radionuclide Radionuclide Radionuclide Radionuclide 1 2 3 4 Radionuclide

Principal radiation (beta, gamma) Half life

Chemical form

Max activity per order (MBq) Maximum quantity to be stored on site for this project (this includes ALL stock and samples) (MBq) Maximum activity used per experiment (MBq) Estimated frequency of usage (per month)

Radioactive waste disposal

Maximum total monthly disposal (MBq) Aqueous waste

Gaseous waste

Solid waste

Organic scintillant waste

Note: The cost of radioactive waste disposals will be charged back to your department.

04/04/2018 49/63 Section 3 Facilities and Documentation

Attach a plan of the radiation laboratory indicating stock and waste storage areas, radiation work areas, designated radioactive sink.

Security and storage: Give details of the building and radioactive lab security and the plans for storage of radioactive stock and samples

Give details of fire safety (smoke detectors etc) in the radioactive work and storage areas

Give details of the ordering (including frequency) and delivery arrangements for radioactive material.

List radiation monitoring equipment available

Monitor and probe Serial Numbers Last calibration date Suitable for radionuclides used?

Documentation

Is a laboratory plan attached? Y/N* Are Local Rules relevant to this work available and approved by the RPA? Y/N*

Is a written protocol available for the proposed work? Y/N*

* Delete as appropriate. If the answer is no then the RPA will not sign the form until agreed suitable remedial action has been taken.

Section 4 Radiation Risk Assessment

04/04/2018 50/63 Attach a copy of the experimental protocol, which must include instructions / methods on keeping doses to personnel as low as reasonably practicable

Best practical means of reducing radionuclide activities used: describe the means by which the stock and waste activity will be minimised (e.g. by minimising activity per experiment, sharing stock with other users in the department)

Radiation Hazards (Describe the possible routes of internal and external contamination)

Persons at risk (persons carrying out the work and persons potentially at risk e.g. cleaners, maintenance personnel)

Control Measures in place to keep doses ALARP (i.e. containment, shielding, personal and environmental monitoring)

Risk Assessment performed by: Position:

04/04/2018 51/63 RPS Signature (if not person above): Date:

THIS DOCUMENT MUST BE REVIEWED ANNUALLY OR WHEN SIGNIFICANT CHANGES IN PRACTICE HAVE OCCURRED OR AUDIT SHOWS THAT A REVIEW IS NECESSARY.

To be completed by RPS

Environment Agency open source registration number

Environment Agency authorisation for disposal of radioactive waste number

Are the isotopes covered by relevant certificates?

Is the ARSAC licence valid for the work (where applicable)

Is the risk assessment satisfactory?

04/04/2018 52/63

Section 5 Approvals (please obtain signatures in order below)

RPS Name...... sig......

Date......

If appropriate, Clinician who will hold ARSAC licence *

Name...... sig...... Date......

Agreement by Project Supervisor

I agree to inform the Health and Safety Office and the RPS of any changes to the protocol as set out in this document including changes in personnel. I agree to comply with the Local Rules and any other conditions which the RPA recommends as a condition of granting approval for this project. I agree to keep comprehensive records of use and disposal of the radioisotopes and agree to provide monthly record returns of source inventories and disposals. I will keep the radioisotopes in a secure place and to follow all recommended safety procedures.

Name...... sig......

Date......

Head of Department/Centre Lead*

Name...... sig......

Date......

RPA Name...... sig......

Date......

NB: The Health and Safety Office and RPS must be informed immediately of any personnel or material changes in protocol or activities or radio-nuclides used in this project.

* The Centre Lead signs on behalf of the Director of Institute.

Appendix 4 b

04/04/2018 53/63 Radiation Protection Risk Assessment Form

Department/Institute Date of Risk Assessment Risk Assessment number

Project Registration Number

Location of work (Campus/Building/Room number(s) and current designation for radiation work)

Procedure (Describe the radioisotope to be used, maximum activity and the general procedure and frequency)

Radiation Hazards

Persons at risk (persons actually and potentially at risk)

Dose Constraints for Exposed Groups (if appropriate).

Potential radiation risk rating

04/04/2018 54/63 Control Measures in place (to keep doses ALARP)

Proposed Designation of Area(s) (Indicate also whether this is a change in status)

Further Actions required (Please indicate who is responsible for these and any timescale required)

Risk Assessment performed by: Position:

RPS Signature (if not person above): Date:

REVIEW WHEN SIGNIFICANT CHANGES IN PRACTICE HAS OCCURRED OR AUDIT SHOWS THAT A REVIEW IS NECESSARY.

cc Head of Department/Institute and RPS.

04/04/2018 55/63 Appendix 4 c

04/04/2018 56/63 Appendix 4 d Inventory of Radioactive Materials Waste and stock control - monthly return

This form must be completed and returned at the beginning of each month (no later than the 10th) to :

Anne Harris Health and Safety Charterhouse Square

These records are a legal condition of our authorisation by the EA. This form MUST be returned even if no waste has been disposed of in the month.

Laboratory Site

Month/year RPS

Radioactive material stock held on the last day of the month (corrected for decay)

Isotope Activity (MBq)

Radioactive material waste disposal

Isotope Physical form and route Activity (MBq) of disposal

04/04/2018 57/63 Appendix 8 a

RADIOISOTOPE DEPARTMENTAL AUDIT FORM PLEASE PRINT DATE : AUDIT CONDUCTED BY : DEPARTMENT : LOCATION : LABORATORY ID : SITE : RPS : PERSON RESPONSIBLE FOR AREA AUDITED: Audit of Department [1] General Indicate Y or N Are there any classified workers in the department (if so give details…)? Do any staff using personal dose monitoring equipment (film badge, TLD, other )? Are there any sealed sources in the department (if so give details….)? Is aqueous waste produced and disposed? If aqueous waste is produced, confirm it is not stored. Is organic (scintillant) waste produced? Is solid waste produced? Is gaseous/aerosol waste produced?

[2] Staff Training Indicate Y or N Has RPS: Been on an appropriate training course? Received letter of appointment? Received list of duties? Percentage of the other staff members that have been on GKT day or equivalent?

[3] Staff Monitoring Indicate Y or N Do all personnel with film badges/TLDs wear them when working with 32P, 125I, 51Cr etc? Are badges exchanged promptly for new ones at the beginning of each month? Is staff register up to date? i.e. no badges arriving for staff who have left etc

[4] Risk Assessments and Project Registrations (The current reg’s require written risk assessments to be available for inspection.) Indicate Y or N Have risk assessments been carried out for new procedures? Has RPS been on the training session for this? Do they need to attend the training session? Have project registrations been completed for the current projects? Are staff aware of the procedure for project approval? [5] Security Review security measures being taken by department personnel: Indicate Y or N Is dept. locked? Are visitors challenged by dept. personnel?

[6] Delivery of Stock & Transport of Radioactive Material On/Off Site Indicate Y or N Is stock delivered directly to department? Is stock ordered by anyone other than RPS? Are deliveries inspected and secured promptly upon receipt? Is radioisotope stock minimised and disposed when no longer in active use? Is Radioactive Material transported off site?

04/04/2018 58/63 If so: a) has this arrangement been approved by the RPA? b) are transport shipper certificates held? c) are stock records updated to reflect the change in amounts held? d) are proper couriers, with appropriate training, used?

[7] Local Rules Indicate Y or N Have all personnel signed that they have read and understood the local rules? Do they need amending i.e. IRR 99, names of staff, new procedures, new site, new RPS etc?

[8] Waste Store Policy Solid Org. Are all personnel familiar with the waste policy for the campus? Are they familiar with the way in which the waste is to be bagged / labelled / calculated? Are staff familiar with the waste store opening days and times? Is radioisotope waste minimised and disposed when no longer in active use?

[9] Wipe Testing of Sealed Sources Indicate Y or N Are there any sealed sources in the lab? i.e. sealed ‘external standard’ in beta counters Are they listed on the site inventory? i.e. included on the update forms issued 3 monthly Are they being leak tested ‘at a suitable interval?’ Have records of the wipe tests been kept for at least 2 years?

04/04/2018 59/63 Appendix 8 b Audit of Individual Rooms / Laboratories

[1] Room Names and Isotopes and Activities Used Room 1 Room 2 Room 3 Room 4

Isotope Activity Isotope Activity Isotope Activity Isotope Activity

Y or N / C or S [2] General Room 1 2 3 4 Radioisotope Workers – How many use this laboratory? Are the local rules posted prominently in the laboratory? Is this a Controlled or Supervised area?

[3] Security Review security measures being taken by lab personnel (see also section 6 1 2 3 4 below): Is lab locked when no-one is present? Are visitors challenged by lab personnel? Are stock vials or labelled samples left to thaw in unattended non-secure areas?

[4] Entrance Doors – Signage 1 2 3 4 Are there appropriate warnings signs and labels on the entrance doors? Do they state the isotopes used in the laboratory and the maximum quantities?

[5] Facilities for Storage of Stock 1 2 3 4 Is room used for storage of stock or experimental samples etc? Are there appropriate warning signs/labels on the fridge/freezer doors? Are the signs clearly visible? Is the fridge/freezer lockable and secure? Is radioactive stock segregated from non-radioactive stock in fridge/freezer? Is the stock shielded appropriately? Are stock vials periodically returned for disposal and inventory sheets collated?

04/04/2018 60/63 [6] Protective Equipment 1 2 3 4 Are gloves, over-shoes and/or masks provided where needed? Are lab coats provided and worn (fastened)? Are splash guards provided? Are suitable length tongs/forceps provided? Are drip trays used routinely together with an absorbent liner?

[7] Work Areas, Flooring & Benches 1 2 3 4 Check the flooring. Is it continuous, undamaged and sealed? Check the benching. Is it appropriate and sealed? Are radioactive work areas demarcated? Are Fume Cupboards labelled for use with radioactive materials? Is testing equipment, used with radioactive materials, marked as potentially contaminated? Are work areas shielded with appropriate shielding (material, thickness) for isotopes used?

[8] Spill Kits 1 2 3 4 Are spill kits available? Are they easily accessible? i.e. do you have to walk over the spill to get to the kit? Are the spill kit locations clearly signed? Check contents, are they adequate for the laboratory needs? Do they have appropriate decontamination fluids? Review radioactive spill or other contamination incident procedures. Do lab staff know how to contact the RPA if a major incident occurred out of hours?

[9] Radiation Monitoring Equipment 1 2 3 4 What type of monitors are available? Are the monitors appropriate for the isotopes used? Are they within calibration? When is next calibration due? Battery OK?

[10] Designated Sinks for Disposal of Aqueous Waste 1 2 3 4 Does room have a designated sink? Is it suitable – does the plumbing potentially compromise other sinks? Is sink clearly labelled as ‘radioactive waste disposal sink’ or similar? Does sink have radiation warning tape around the U-bend and flow pipe? Is sink / bench joint securely sealed? Is there a wash hand basin readily available?

[11] Facilities for Storage of Waste 1 2 3 4 Is room used for storage of solid or organic liquid waste? Are isotopes segregated in waste bags/drums? Is solid waste shielded with appropriate shielding (material, thickness)? Is any unshielded solid waste close to work areas ? Is the bin designated for radioactive solid waste appropriate? Is it clearly labelled ‘radioactive solid waste’ etc? Are there bins designated as ‘non-radioactive’ in the room Are they clearly labelled as ‘non-radioactive clinical waste’ or similar? Has the currently stored solid waste been stored for over 6 months? Is organic waste stored in appropriate drums? Has the currently stored organic waste been stored for over 3 months?

04/04/2018 61/63 [12] Dosimetry and Record Keeping for Stock, Waste and Environmental and

Personal Contamination Monitoring 1 2 3 4 Is the ISOSTOCK record keeping system employed, as required by the School? Are the stock records acceptable? Are the waste records acceptable? Is monitoring performed for all isotopes? Are monitoring records kept? Are they up to date? Are they complete? How often is contamination monitoring performed for: a) Environment? (Weekly, Daily, per Experiment, Other-specify below) b) Personal Monitoring?

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04/04/2018 62/63 LABORATORY PLAN