(This policy became effective on November 8, 2000 on which date it was approved by the Radiation Safety Committee. It will not be retroactive in terms of previously identified items of non-compliance.)

1. Purpose

The Radiation Safety Office (RSOF) works in the interest of the university by supporting research. The structure of the program is continually refined to minimize restrictions on research activities while assuring compliance with the requirements of all regulatory agencies, particularly those of the Ohio Department of Health (ODH).

Compliance with radiation safety program requirements is very good, and we acknowledge the excellent cooperation of the research staff responsible for this success. Nonetheless, certain actions perceived by an individual to be safe or harmless may in fact result in serious consequences for the university. In other words, even a single, unintentional oversight can have serious consequences.

This enforcement policy is designed to encourage the participation and cooperation of users of radioactive material (RAM) to ensure safe use of such material consistent with the rules and regulations of the ODH as interpreted by the Radiation Safety Committee (RSC) and the RSOF.

2. Policy

The responsibility for safe use of radioactive materials is placed on the authorized users as well as on the RSOF and the RSC. A system of consequences for violations of regulations concerning safe use of RAM will be used for educating and alerting the authorized users, motivating individual users, and determining authorized user status.

A violation will generally be identified by a member of the RSOF during a routine compliance inspection, monthly security check, or laboratory survey. This does not preclude violations being identified at other times or being identified through self-reporting by an authorized user (AU). We are reinstituting the policy of providing each AU with a copy of the compliance review sheet following each compliance inspection. This will be done whether any deficiencies are identified or not.

We have simply defined three classes of deficiencies, minor, moderate, and severe. The specific acts that are included in a deficiency category are listed below.

As herein used, the abbreviation "RSO" shall mean the radiation safety officer or the assistant radiation safety officer.

3. Enforcement
1. Spills and accidents are not violations unless they are the result of failure to comply with regulations and/or conditions of an AU’s approved protocol for use of RAM.
2. The violations listed here are not all-inclusive. The lists may change as deemed necessary by the RSC.
3. Minor violations are:

Laboratory Records:

1. RAM shipments not monitored or recorded.
2. RAM sewer disposals not recorded or exceeding limits.
3. Sewer disposal logs do not indicate isotope, activity, date, or chemical form of the isotope.
4. Minimum survey frequency not met (within a two week grace period).
5. Surveys not done with proper instruments.
6. Survey results not converted to activity units when activity levels due to contamination exceed background levels.
7. RAM waste disposal records not in order.

RAM Use and Storage

8. RAM containers not labelled as to isotope and activity.
9. RAM not appropriately shielded.
10. Lab work surfaces not covered during RAM use.
11. RAM work areas not properly labelled.
12. Calibrated survey meter not available or not functional.
13. Dosimeters not worn when appropriate.
14. Appropriate personnel protective equipment (PPE) not used during RAM use.

Lab Environment / General Safety

15. RAM waste not labelled with isotope and estimated (or maximum) activity.
16. RAM waste not properly segregated and shielded.
17. Liquid waste not doubly contained.

 

4. Corrective Action for Minor Violations

   When three minor violations have occurred within the calendar year:

   1. Written notice sent to the AU following approval and verification by the RSO.
   2. Failure to take corrective actions within the requested time frame will result in termination of isotope ordering privileges until the AU satisfies the RSO that appropriate corrective measures have been taken.

 

5. Moderate severity violations are:
   1. Storage or use of food, drink or cosmetics including hand lotion in a RAM posted laboratory. (FOOD OR COSMETICS IN LAB)
   2. Failure to properly secure RAM. (RAM UNSECURED)
   3. Use or storage of RAM in unauthorized areas. (RAM IN UNAUTHORIZED AREAS)
   4. Failure to notify the RSOF prior to laboratory move. (UNAPPROVED MOVE)
   5. Failure to inform RSOF prior to disposal of contaminated (or potentially contaminated) equipment. (UNAPPROVED DISPOSAL)
   6. Failure of laboratory personnel to identify contamination exceeding 2200 dpm/100 cm² in more than one location in work areas (UNIDENT. CONTAMINATION)

    

6. Two moderate severity violations in a calendar year will result in:
   1. Written and verbal notification by the RSO to the AU, with written notice sent to the AU’s department chair and department administrator.
   2. Failure to take corrective actions within the requested time frame will result in termination of isotope ordering privileges until the AU satisfies the RSO that appropriate corrective measures have been taken.

7. Major severity violations are:
   1. Intentional falsification of required radiation safety records. (FALSIFICATION OF RECORDS)
   2. Failure to immediately report known loss or theft of radioactive material. (LOSS OR THEFT UNREPORTED)
   3. Unauthorized external shipment or receipt from external source of radioactive material. (UNAPPROVED TRANSFER)
   4. Failure to respond to a written notice from the RSO within the requested time frame following initial receipt. (FAILURE TO RESPOND TO WRITTEN NOTICES) Notices requiring responses will conspicuously indicate the need for a response and the associated time frame to ensure there is no ambiguity as regards this requirement.

    

8. A major severity violation will result in:
   1. Immediate verbal notification of the AU by the RSO.
   2. Written notification sent to the AU by the RSO with copies sent to the AU’s department chair and to the RSC chair.
   3. Suspension of RAM ordering privileges until the item is resolved to the satisfaction of the RSO and the RSC chair.
   4. Possible suspension of authorization to use RAM, at the discretion of the RSO pending review by the RSC

1. Appeal Process

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© 2004 Case Western Reserve University | Cleveland, Ohio 44106 | 216.368.2000 | legal notice