Compliance checks will be performed during routine (weekly or monthly) surveys of the RMAs. Findings will be reported to the PI and documented in the RWA files. Three levels of noncompliance findings have been established. Safety-significant findings (Level 3) require review by the Radiation Safety Committee.
LEVEL 1: RWA Project PIs will be notified directly of all Level 1 findings. The project has 30 days to correct those findings requiring action. If the same noncompliance item is identified during the next monthly OHP survey, the finding is elevated to a Level 2.
1. Proper protective clothing not worn while handling radioactive material.
2. Radiological waste containers not labeled indicating isotope disposed within. Benchtop containers are to be labeled indicating the isotope, date, and approximate amount disposed.
3. User surveys not documented or performed at the required frequency. Survey maps and associated results are to be completed and filed in the radioisotope journal.
4. “Daily Use Logs” not completed. The logs are to be used to indicate the amount of material removed from each stock vial and the amount disposed of as waste or held in long-term storage.
5. Authorized radionuclide possession limit exceeded.
6. Posting and labeling of RMAs or RSAs not correct or missing.
7. TLD or bioassay sample not provided in a timely manner.
8. On-the-job-training forms not maintained as required. Completed job-specific training forms are required for unsealed isotope radiation workers as well as x-ray machine and sealed source radiation workers.
9. Transfer of radioactive material or sealed source to an authorized project not properly documented. Daily use logs are to accompany the transfer of unsealed material. Transfer of a sealed source requires documentation in the sealed source use log and notification of the source custodian.
10. Contamination levels in RMA or RSA found to exceed values in 10 CFR 825, Appendix D.
11. Poor housekeeping in RMA or RSA.
12. Other Level 1 non-compliance findings identified by an OHP Health Physicist.
LEVEL 2: RWA Project PIs, the PI's division director, and radiation workers will be notified directly of all Level 2 findings. The project has 30 days to correct those findings requiring action. If the same noncompliance item is identified during the next required OHP survey (within 30 days), the finding is elevated to a Level 3.
1. Level 1 findings (observations) not corrected within 30 days of notification.
2. Five or more Level 1 findings identified within the same month.
3. Personnel contamination, contamination outside an RMA, or contamination on the floor within the RMA not promptly reported to the Operational Health Physics (OHP) Group.
4. Dosimetry not worn during work with radioactive material as required by the RWA.
5. Receipt or purchase of material greater than the currently authorized vial limit.
6. Food, drink, or smoking in an RMA or RSA.
7. Unsupervised work with radioactive material or use of radiation-producing machines (including x-ray machines) without required radiation safety training or on-the-job training.
8. Transfer of radioactive material, sealed sources, or x-ray equipment to unauthorized projects.
9. Use of facilities for radiological work not authorized in the RWA.
10. Release of contaminated materials or equipment for unrestricted use without prior authorization.
11. Safety interlock violation that would not under normal circumstances lead to an exposure greater than 5 rem.
12. Radioactive material found in regular trash.
13. Release of radioactive material to the sewer without RWA authorization.
14. Radioactive material improperly transferred between RMAs or RWAs.
15. Quarterly inventory not updated or returned to OHP as required.
16. Other Level 2 non-compliance findings identified by an OHP Health Physicist.
LEVEL 3 (Safety Significant): The PI and the PI's division director will be notified of all Level 3 findings. RWA suspension is at the discretion of the Radiological Control Manager. A review by the Radiation Safety Committee is required prior to re-instating the RWA.
1. Level 2 findings not corrected within 30 days of notification.
2. Five or more Level 2 findings identified within the same month.
3. Failure to control clear and present danger to worker health and safety, e.g., worker exposure above regulatory limits ( 5 rem whole body, 50 rem skin or extremity, and 15 rem eye).
4. Reportable occurrences or noncompliance with 10 CFR 835 that have safety significance and/or are due to willful carelessness or negligence.
5. Falsification of surveys or records.
6. Willful, unauthorized violation of an interlock system used for radiological safety that has potential for a radiation exposure in excess of limits specified in 10 CFR 835, whether or not such an exposure occurs. An example is operation of a facility with a nonfunctioning interlock system or entry into high radiation areas without having performed an adequate survey.
7. Willful, unauthorized release of radioactive material or contaminated articles off site that poses a realistic potential for exposure of the public to levels or doses exceeding the annual dose limit for members of the public.