Generic Local Rules template for the Royal Free and University College Medical School (Hampstead Campus) Please read through and make alterations to suit your department practice. Royal Free & University College Medical School (Hampstead Campus)
LOCAL RULES
Relating to the Safe Use of Ionising Radiation
In the Department of
YOUR DEPARTMENT
In Compliance with The Ionising Radiations Regulations 1999
Approved by:
Lab Manager / Dept. Head (sign) (Date)
RPA: Dr J Agnew
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 1 of 16 Review date : Yr later CONTENTS
1 Introduction. 3 2 Responsibilities and Duties 3 3 Name and Contact Numbers 4 4 Designation of Staff 4 5 Designation of Controlled & Supervised Areas 4 6 Designation of Persons 5 6.1 Radiation workers 5 6.2 Domestic and Estate staff 5 6.3 Visitors 6 6.4 Radiation workers who are pregnant 6 6.5 Other pregnant staff 6
7 Personal Radiation Monitoring 8 Control over radioactive Substances
9 System of Work in XXX
10 System of Work for Personal Decontamination
11 System of Work for Contamination Monitoring
12 System of Work for Disposal of Waste
13 Contingency Plans 9.1 Fire 9.2 Theft or Loss
14 Radiation Risk Assessment
15 Staff Training
16 Appendices SCOPE OF THESE LOCAL RULES
These rules apply to all work relating to the use of radionuclides carried out in XXXX.
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 2 of 16 Review date : Yr later These local rules are subject to change with alterations in work practices and outcomes of audit and risk assessments.
1. INTRODUCTION
These rules are intended to ensure compliance with the Ionising Radiations Regulations of 1999 (IRR99), the Radioactive Substances Act 1993 (RSA93) and the approved code of practice (work with ionising radiation) 2000 (‘ACOP’). IRR99 and the ACOP require that local rules be available for any area in the School where there is a risk to staff from ionising radiation. In addition they must be used in conjunction with any Systems of Work prepared for specific procedures The School’s Radiation Protection Policy outlines the responsibilities of the Managers and Staff with regard to ionising radiation; and sets out mechanisms whereby the School intends to discharge its responsibilities as an employer with respect to the relevant legislation.
These Local Rules are the means by which staff working in XXX comply with these legislative requirements. The Local Rules must be available to staff at all times. The Local Rules will be kept with the manager. A summary sheet of these Local Rules is displayed (state where).
2. RESPONSIBILITIES AND DUTIES
The Royal Free & University College Medical School (Hampstead Campus), as the Radiation Employer, has ultimate responsibility for all matters relating to Health and Safety, including radiation safety, of its employees and all other persons on their premises.
Lab Manager – responsible for compliance with IRR’99 in XXX. S/He must ensure that Local Rules and Systems of Work are in place and complied with; and must arrange for the appointment of suitable Radiation Protection Supervisors and ensure they are aware of their duties. Radiation Protection Advisor (RPA) – appointed in writing by the Royal Free & University College Medical School to advise on issues of compliance with the legislation and give advice on all radiation safety matters.
Radiation Protection Supervisor (RPS) – appointed in writing by the Royal Free & University College Medical School to supervise the work so that it is carried out in accordance with the Local Rules. An RPS is a local contact for a specific area, and local problems regarding radiation should first be addressed to them. The RPS should report to the Lab Manager any problems of non-compliance with the Local Rules, but it is not the duty of the RPS to enforce the Local Rules.
All Employees, Visiting Workers, Trainees and Students – All radiation workers are required to read these Local Rules and to agree, by signature, to act in accordance with
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 3 of 16 Review date : Yr later them. This also applies when new Local Rules or revisions are issued. Breaches of the Local Rules may lead to disciplinary action.
Any queries regarding radiation safety should be addressed to the RPS, RPA or members of the Radiation Safety Group.
3. NAME AND CONTACT NUMBERS
Name Title Contact details Lab manager Radiation Protection Supervisors (RPS) Deputy Radiation Protection Supervisor Radiation Protection Advisor(s) Ext 33208 or Dr John Agnew (RPA) 0207 8302471 Miss Claire Skinner Head of Radiation Safety Ext. 33759 (pager 1063)
Mr Jeff Jones Personal Monitoring Ext. 33759
4 DESIGNATION OF STAFF
Employees working with radiation in the Royal Free & University College Medical School are currently designated as non-classified workers. Dose records are kept for at least 2 years to confirm their non-classified status.
A classified worker is someone who is likely to receive a radiation dose from routine work which exceeds three tenths of any dose limit. Currently, there are no classified workers in the Medical School and this is not expected to change within the immediate future.
5 DESIGNATION OF CONTROLLED & SUPERVISED AREAS Areas are designated as Controlled Areas as defined by Regulation 16 of the Ionising Radiations Regulations 1999 and the Approved Code of Practice.
Controlled Area – an area where a person is likely to receive a dose greater than three- tenths of any relevant dose limit. Any area can be designated as a Controlled Area at the discretion of the RPA and/or RPS.
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 4 of 16 Review date : Yr later Supervised Area – an area where a person is likely to receive a dose greater than one- tenth of any relevant dose limit. Again, any area can be designated as a Supervised Area at the discretion of the RPA and/or RPS.
Rooms XXX are designated as Controlled/Supervised Areas because radioactive substances are stored and manipulated in there (cf. Appendix 1). There is a potential for the room to be contaminated and doserates may be such that the room requires some degree of control.
6 DESIGNATION OF PERSONS Entry to this laboratory is restricted to appropriately trained staff who enter in accordance with these written arrangements.
No person other than appropriately trained staff are allowed to enter the Controlled area except under exceptional circumstances. Under these exceptional circumstances, the Lab manager / RPS needs to be informed. Persons may fall into one or more of the following categories:
6.1 Radiation workers
These include all staff who routinely work with ionising radiation.
Including: ?????? Radiation Safety Physicists and trainee Physicists Radiation Safety Medical Technical Officers
Radiation workers must ensure that: They have read and understood these Local Rules if they are entering the Controlled area. They have to agree by signature to comply with them. They are wearing their Personal Dose Monitor if they have been issued with one. The systems of work relating to the safe use of radionuclides are observed at all times.
6.2 Domestic and Estates staff
These staff: Must obtain prior permission from the Lab manager or RPS to enter a Controlled Area. Maintenance work must not be undertaken without a “Permit to Work” Under normal circumstances, there is no need for either group of staff to enter the Controlled Area.
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 5 of 16 Review date : Yr later If access is required for a short period only, consent must be obtained from the Lab manager or RPS first and the person must be supervised by the RPS or a member of staff nominated by the RPS at all times.
6.3 Visitors No visitors are allowed in the Controlled Area at any time except for professional visitors escorted by the RPA, Lab manager, RPS or a member of staff nominated by the RPS
6.4 Radiation workers who are pregnant A pregnant member of staff may choose whether or not she will formally declare her pregnancy. It is strongly recommended that such a declaration is made in order that steps may be taken to restrict the dose to the foetus. If declared this must be in writing to the member of staff’s manager. The manager must inform the Radiation Safety Group (RSG). Duties will be reviewed following the completion of a Risk Assessment and steps taken to minimise the dose to the abdomen as far as is practicable and to ensure that the dose limit for the abdomen is not exceeded during the declared term of pregnancy. Information will be treated as confidential. If a pregnant member of staff chooses not to declare her pregnancy, only the radiation limits for adult radiation workers will be in effect, not those for the foetus.
6.5 Other pregnant staff Pregnant staff from other departments, should not enter radiation areas during their pregnancy except with prior agreement from the RPS, MPE and/or RPA.
7 PERSONAL RADIATION MONITORING
All staff working with radionuclides must wear a personal dosimeter if they have been issued with one. This can be obtained by filling in a dosimeter application form that can be downloaded from the intranet or be obtained from the RSG. The dosimeter should be worn on the trunk, at chest or waist level or as directed by the RPS. Care should be taken to ensure that the dosimeter is not obscured by other objects e.g. pens.
Dosimeters are issued monthly. Staff should ensure that they change their dosimeter every month.
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 6 of 16 Review date : Yr later If a personal dosimeter is lost or damaged, or is exposed to ionising radiation when not being worn, this must be reported to the RSG.
When not on duty personal dosimeters should not be left in the lab.
Dose Investigation Levels In the event of a member of staff receiving a dose greater than the local investigation level of 0.1mSv per month, a review of that person’s working practice must be undertaken by that member of staff’s RPS to assess how they might have received the radiation dose.
In the event of doses exceeding the formal Dose Investigation Level of 0.5mSv per month, a review and formal investigation of that person’s working practice must be undertaken by the RPA and staff from the RSG with the RPS to assess how they might have received the radiation dose.
Following investigation, remedial action may be necessary to change working practices.
Any doses exceeding the formal Dose Investigation Level must be reported by a member of the RSG at the next Radiation Protection Committee meeting.
8 CONTROL OVER RADIOACTIVE SUBSTANCES
Careful accounting of the quantity and location of all radioactive substances is a requirement of the Ionising Radiations Regulations 1999 (IRR99). Records must be kept for at least 2 years from the date of the last entry made and at least 2 years from the disposal of the substances(s) in question.
Further requirements for radioactive waste minimisation are required in order to demonstrate compliance with the Certificate of Authorisation issued to the Medical School (Hampstead Campus) under the Radioactive Substances Act 1993. In particular all ordering, handling, storage and disposal of radioactive substances must comply with the “Best Practicable Means” (BPM) certificate condition. [Add reference here to the BPM Compliance Statement specific to your Department.]
Many aspects of adherence to both IRR99 and BPM requirements will be achieved by: (a) following Good Laboratory Practice (b) adhering to the Systems of Work set out below (c) taking care at all times over the containment and security of all radioactive substances.
9 SYSTEMS OF WORK FOR Room(s) X-NNN
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 7 of 16 Review date : Yr later 1. Radionuclides must only be used in the designated areas in room(s)NNN.
2. Entry to these controlled areas is restricted to appropriately trained staff who enter in accordance with the “written arrangements”.
3. Workers must monitor the work area for radioactive contamination before and after all work with dispersible radioactive materials. The results of this monitoring must be recorded. Any contamination found before work commences must be reported to the Radiation Protection Supervisor (RPS).
4. All persons intending to use radionuclides must first fill out a form “To Use Radionuclides” (which can be downloaded from the intranet). This must be signed by the RPS and the Head of Department and sent to the Radiation Safety Group to be signed by the Head of Radiation Safety.
5. Procedures should be designed to protect staff and minimise the spread of activity from the working area.
6. Workers must fully account for all radioactive material used and disposed so that the whereabouts of all radioactive substances are known at all times and any losses are quickly detected.
7. Eating, drinking, smoking and applying cosmetics etc. are forbidden.
8. All radionuclides stock solutions must be kept in one of the designated refrigerators/ freezers or safes. These are sited in Rooms X-MMM & X-PPP. Storage areas for radioactivity must be kept locked at all times. Unused materials must be returned to the store immediately after work with radioactive materials is complete.
9. All procedures using radionuclides must be recorded at the time of use on the record sheets provided; these must remain in the Hot Room X-NNN. Likewise all workstations must be monitored and readings recoded in log sheets provided.
10.All contaminated solid waste must be disposed of in designated bags provided.
11.Contaminated re-usable glassware and equipment must be decontaminated with the aid of a decontamination solution such as Decon 90 before removal for washing up in the general wash up room.
12.The operation of pipettes by mouth is forbidden.
13.Only designated sinks may be used when disposing of aqueous radioactive waste.
14.Use the hand basin for hand washing. Monitor hands for contamination before leaving the laboratory.
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 8 of 16 Review date : Yr later 15.Laboratory coats and appropriate PPE including latex/nitrile gloves must be worn for all procedures. Gloves used for handling radioactive substances or patient derived material must not be worn outside the laboratory. Care must be taken to dispose of these gloves in the appropriate radioactive solid waste bins.
16.In the event of an accident or incident involving radioactive materials inform the RPS immediately.
17.In the event of hearing the continuous fire alarm the department must be evacuated. All radioactive sources should, if possible, be returned to store.
18.Any real or suspected loss of any radioactive source (including waste) must immediately be notified to the RPS and RPA, who may have to notify the Health & Safety Executive and/or the Environment Agency.
19.When the RPS is not available, the RPA may be contacted. When the RPA is not available, advice may be obtained from the Radiation Safety Group (ext: 33759).
20.Any work not covered by specific Systems of Work or other written procedures should be carried out in accordance with generally accepted good practice paying particular attention to recommendations in the Approved Code of Practice and Guidance Notes relating to the Ionising Radiations Regulations of 1999, and in the Radioactive Substances 1993 Act.
21.The door to the radioactive laboratory must be kept locked at all times when it is not occupied.
10 System of Work for Personal Decontamination
If radioactive contamination of the skin has been detected:
1. Wash affected area with soap and water as soon as possible.
2. If washing the contaminated skin with soap and water fails to reduce the contamination to background levels, a detergent or chelating agent specific to the chemical form of the contaminant should be used. The hands should not be brushed vigorously, nor should chemical treatment be attempted, as these may damage the skin.
3. When high level contamination of parts of the body, other than the hands, is suspected, or when procedures described above for decontamination of the hands are ineffective, the RPS (or the deputy) and the RPA and/or member of the Radiation Safety Group should be notified at once and consideration given to any
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 9 of 16 Review date : Yr later further action. Special care needs to be taken in the decontamination of areas near the eyes and in preventing spread of contamination to other parts of the body.
4. If the skin is broken or a wound is sustained in conditions where there is a risk of radioactive contamination, the injury should be irrigated immediately with running tap water, taking care not to wash contamination to other areas of the body. As soon as the first aid measures have been taken, the person should seek further treatment, including decontamination if necessary. In such cases it is essential that details of the incident are recorded in the person’s medical records. Advice on medical treatment is given, for example, in Manual on Early Medical Treatment of Possible Radiation Injury: IAEA Safety Series No. 47.
5. All incidents involving personal contamination must be reported to the RPS.
11 System of work for contamination monitoring
1. Monitoring is to be carried out before and after work with radionuclides by the worker using a Geiger or scintillation monitor. (be more specific if you can)
2. A ‘battery check’ will have to be made first by ensuring that the needle does not drift out of the ‘green zone’ over a 30 second period.
3. With the monitor turned on, check the background level in a low background area.
4. Bench, hands and clothing must be monitored before and after completion of the procedure and the counts per second (cps), above background, recorded on the log sheets.
5. In the event of a spill / contamination, the RPS must be informed even if the spill has been contained. PPE must be worn and the area decontaminated using the spill kit provided. The area must be monitored before being passed as ‘fit for use’.
6. When monitoring has finished, ensure that the monitor is switched off.
7. Record all results – even when the result is zero.
11 System of work for Disposal
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 10 of 16 Review date : Yr later 1. Solid waste should be disposed of in the grey polythene disposal bags provided. Waste bags must never be filled more than two-thirds.
2. Each bag is designated for a particular radionuclide and must be clearly labelled both during use and at the time of disposal. Do not mix radionuclide waste unless it comes from experiments where mixed radionuclides are used.
3. Before removal from the department each waste bag must be labelled with a unique identification waste label (e.g. DEPs 0001).
4. Care must be taken when removing waste bags from the department, protective clothing must be worn and bags must be moved in a manner that provides adequate shielding for the radionuclide used (expand here for the type of shielding you use)
5. The sealed bags must be taken to the radioactive waste store (located on the service level) on the designated days at designated times (see your RPS).
6. Waste bags from a department will not be accepted in the waste store if the unique identification waste label number is out of sequence.
7. Radioactive liquid waste must be disposed of in the designated sinks only. Each disposal must be recorded, with the date, approximate activity and radionuclide disposed of.
12 CONTINGENCY PLANS
12.1 FIRE In the event of fire, 1. Everyone in the lab must stop what they are doing. All radioactive sources should, if possible, be returned to store. The lab should be evacuated either by the main entrance (preferably) or side door. The last person leaving should close the door behind them and go as quickly as possible to ????.
2. The RPS/ lab manager and/or Head of the RSG must then be informed.
12.2 THEFT Or LOSS OF A RADIONUCLIDE In the event of theft or loss of a radionuclide,
1. The RPS/ lab manager and/or Head of the RSG must be informed immediately.
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 11 of 16 Review date : Yr later 2. All reasonable steps must be taken as promptly as possible to try to recover the item(s) in question.
3. Any real or suspected loss of any radioactive source (including waste) must immediately be notified to the RPS and the RSG. 4. The RPA and/or a senior manager will inform the Environment Agency and HSE in writing.
13 RADIATION RISK ASSESSMENTS
These should be carried out by the RPS / lab manager with guidance from the RPA and/or a member of the RSG.
(add list of Risk assessments that have been done in Appendix 4. When reviewed, any significant risks both “general” and “radiation” which have been noted needs to have the respective action added to these Rules)
14 STAFF TRAINING
All staff using radioactive substances must have prior Radiation Safety training.
Training records must be kept with the department’s manager or deputy and be available for inspection.
All staff using lab XXX must have read and understood the Local Rules and signed the declaration form (cf. Appendix 2) and return the signed copy to the RPS. A copy can be kept for the person’s own records.
All staff must attend an update training session at least once every 5 years.
15 APPENDICES
Appendix 1 Plan of Controlled Area in XXX
Appendix 2 System of work - one page summary sheet
Appendix 3 Staff Declaration form
Appendix 4 List of Risk Assessments
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 12 of 16 Review date : Yr later Appendix 1 Plan of Controlled Area in XXXX
(put your drawing here)
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 1 of 16 Review date : Yr later Appendix 2 : SUMMARY of SYSTEMS OF WORK IN XXX
1 Entry to these controlled areas is restricted to appropriately trained staff who enter in accordance with the “written arrangements”.
2 Workers must monitor the work area for radioactive contamination before and after all work with dispersible radioactive materials. The results of this monitoring must be recorded. Any contamination found before work commences must be reported to the RPS.
3 Eating, drinking, smoking and applying cosmetics etc. are forbidden.
4 All radionuclides stock solutions must be kept in one of the designated refrigerators/ freezers or safes. These are sited in Rooms X-MMM & X- PPP. Storage areas for radioactivity must be kept locked at all times. Unused materials must be returned to the store immediately after work with radioactive materials is complete.
5 All procedures using radionuclides must be recorded at the time of use on the record sheets provided.
6 All contaminated solid waste must be disposed of in designated bags provided.
7 Contaminated re-usable glassware and equipment must be decontaminated with the aid of a decontamination solution such as Decon 90 before removal for washing up in the general wash up room.
8 Only designated sinks may be used when disposing of aqueous radioactive waste.
9 Laboratory coats and appropriate PPE including latex/nitrile gloves must be worn for all procedures. Gloves used for handling radioactive substances or patient derived material must not be worn outside the laboratory. Care must be taken to dispose of these gloves in the appropriate radioactive solid waste bins.
10 In the event of an accident or incident involving radioactive materials inform the RPS immediately.
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 2 of 16 Review date : Yr later 11 When the RPS is not available, the RPA may be contacted. When the RPA is not available, advice may be obtained from the Radiation Safety Group (ext: 33759).
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 3 of 16 Review date : Yr later Appendix 3 Staff Declaration Form
LOCAL RULES RELATING TO RADIATION SAFETY IN XXX
I declare that I have read and understood the Local Rules (dated dd/mm/yyyy), and I agree to abide by them.
Name (print): ………………………………………………………………….
Department: ……………………………………………………………………
Date: ………………………………………………………………………………
Signature: …………………………………………………………………….…
Send one copy to:
Departmental Radiation Protection Supervisor
Retain one copy for your own records.
Adapted by : Your name Document Ref : LR-(wastelabID)1 Effective from : Written By : Date Adapted : 8/8/06 Page No. : Page 4 of 16 Review date : Yr later