Chapter 21
RADIATION SAFETY

Contents

Approved by David Kestell
Revised 05/09

21.1 Policy
21.1.1 General
21.1.2 Radiation Safety Committee
21.1.3 Violations
21.2 Nuclear Safety Program
21.3 ALARA Program at Berkeley Lab
21.3.1 ALARA Program Overview
21.3.2 ALARA Design Review
21.3.3 ALARA Work Reviews
21.3.4 ALARA Dosimetry Reviews
21.3.5 ALARA Reports

21.4 Radiation Protection Program
21.4.1 Group Organization
21.4.2 PAAA Program
21.4.3 Service Contacts

21.5 Responsibilities
21.5.1 Radiation Workers
21.5.2 Supervisors and Principal Investigators

21.6 Radiological Work Authorization and Permit Programs
21.6.1 Radiological Work Authorization (RWA)
21.6.2 Radiological Work Permit (RWP)
21.6.3 Sealed Source Authorization (SSA)
21.6.4 Low Activity Source Authorization (LAS)
21.6.5 Generally Licensed Source Authorization (GLA)
21.6.6 Control and Accountability of Radioactive Material
21.7 X-Ray Authorizations
21.7.1 General
21.7.2 Responsibility
21.7.3 X-Ray Machine Safety Documents
21.7.4 System Safety Analysis
21.7.5 Interlocks and Indicators
21.7.6 Override of X-Ray Safety System Interlocks
21.7.7 X-Ray Machine Design
21.7.8 Posting
21.7.9 Records
21.7.10 Dosimetry
21.7.11 Radiation Safety Surveys
21.7.12 Routine Interlock Testing
21.7.13 Modifications
21.7.14 Use Control
21.7.15 Training
21.7.16 Instrumentation
21.7.17 New Installations
21.7.18 X-Ray Machine Classifications and Specific Supplemental Requirements
21.7.19 Variances

21.8 Additional Authorization Requirements
21.8.1 Accelerators
21.8.2 Irradiators

21.9 Dosimetry

21.9.1 Personnel Radiation Exposure Limits and Controls
21.9.2 Radiation Workers
21.9.3 Workers Under 18 Years Old
21.9.4 Declared Pregnant Workers
21.9.5 Nonemployees and Visitors
21.9.6 Radiation Dose Reports
21.9.7 External Dosimetry Program
21.9.8 Internal Dosimetry Program
21.9.9 Area Monitoring Dosimeters

21.10 Workplace and Environmental Monitoring
21.10.1 Instruments
21.10.2 Surveys
21.10.3 Airborne Sampling
21.10.4 Environmental Sampling
21.11 Radiation Safety Requirements
21.11.1 Radiation Safety Training
21.11.2 Controlled Areas, Posting, and Access
21.11.3 Radioactive Materials Safety
21.11.4 Radioactive Waste
21.11.5 Procurement of Radioactive Material
21.11.6 Transportation and Shipment of Radioactive Material
21.11.7 Decontamination of Radioactive Equipment

21.12 Procedures for Emergencies Involving Radioactive Material
21.12.1 Responsibilities
21.12.2 Spill Classification
21.12.3 Handling a Radiological Emergency
21.12.4 Reporting an Emergency
21.12.5 Suspected Radioactive Contamination to Personnel or an Area
21.12.6 Injured Personnel and Suspected Radioactive Contamination to Personnel or to an Area
21.12.7 Personnel Contamination
21.12.8 Investigation

21.13 Glossary
21.14 Standards
21.15 Related PUB-3000 Chapters
21.16 References
21.17 Appendices

Appendix A. RWA Performance Evaluation
Appendix B: Sealed Source Performance Evaluation
Appendix C: Low Activity Source Authorization Limits

 

NOTE:
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21.1 Policy

21.1.1 General

It is Berkeley Lab policy that all types of radiological work activities will be conducted in accordance with applicable federal law and DOE requirements. This is achieved by adherence to Berkeley Lab policies set forth in this chapter and the related programs and procedures implemented by the Radiation Protection Group (RPG). RPG communicates to line management the specific work requirements applicable to individual facilities and projects through authorization documents such as

Line managers are accountable for implementation and compliance with these radiation safety requirements as they apply to their facilities. RPG personnel provide support by performing the appropriate hazard evaluations, developing the applicable radiation safety authorization documents, and providing all necessary field support services. These field services include hazard evaluation, surveys and radiation monitoring, dosimetry, bioassay, instrumentation, and oversight of work activities.

21.1.2 Radiation Safety Committee

The Radiation Safety Committee (RSC), which is appointed by and reports to the Laboratory Director, is responsible for advising LBNL management on all matters related to occupational and environmental radiation safety. The RSC reviews and recommends approval of radiation safety policies. The scope of its actions will generally be in issues of broad institutional concern and impact, or areas of potential high consequence either in terms of safety or institutional needs. The RSC must also provide a forum to ensure that important radiation safety issues receive appropriate, balanced, and expert review before being acted upon by the Environment, Health, and Safety (EH&S) Division.

21.1.3 Violations

Violations of this policy may result in restrictions from radiological work and/or disciplinary actions by line management. Serious violations of the policy, which are knowingly and willfully committed, may result in civil penalties or criminal prosecution, as determined by applicable federal agencies.

Radiological work may be stopped by a worker through line management, line supervision, or the Radiological Control Manager (RCM) if radiological controls are inadequate or are not being implemented.

21.2 Nuclear Safety Program

Part 830 of Title 10 in the Code of Federal Regulations (10CFR830, Nuclear Safety Management) requires LBNL to accurately and completely characterize each LBNL facility containing radioactive and/or fissionable materials. This Nuclear Safety Program is planned, conducted, and documented by LBNL in accordance with DOE Standard STD 1027-92 CN1, Hazard Categorization and Accident Analysis Techniques.

LBNL facility inventories will be managed and monitored to ensure only radiological facilities occur (i.e., radiological inventories maintained below those defined in DOE STD 1027-92 CN1 for a Hazard Category 3 nonreactor nuclear facility). These management and inventory controls are implemented by the Radiation Protection Group with management oversight by the Radiological Control Manager and institutional oversight by the Radiation Safety Committee and the Office of Contract Assurance.

21.3 ALARA Program at Berkeley Lab

21.3.1 ALARA Program Overview

Title 10 of the Code of Federal Regulations (CFR), Section 835.101(c), requires that there be a formal documented program at LBNL that is designed to ensure that radiation exposures are maintained as low as is reasonably achievable (ALARA). The primary mechanisms for training personnel, monitoring the workplace, controlling work activities, and maintaining radiation exposures ALARA are implemented through the authorization system, worker awareness, and RPG's monitoring (individual and area) and surveillance activities.

Oversight of the ALARA Program is provided through quarterly reviews by the Radiation Safety Committee (RSC) in conjunction with the Radiological Control Manager (RCM). Annually, the RSC meets with the Laboratory Director and provides a summary of ALARA activities and reports.

The elements of the ALARA program include the following:

The people who have the most important role in reducing exposure, waste, and environmental effluents are the workers who use radioactive materials and radiation-producing devices. For each job involving exposure to radiation or radioactive material, each worker is responsible for understanding the job requirements, the radiological control measures, and ALARA practices. Workers and their managers are responsible for being aware of and understanding the radiation hazards in the workplace.

Techniques for reducing exposures include the use of distance, time, and shielding, and the use of proper engineering controls such as glove boxes.

The authorization program provides a mechanism for the RCM to assess work, and to devise and implement controls designed to limit exposure. RSC has an oversight role in that they review authorizations, develop ALARA goals, assess progress toward those goals, and conduct independent ALARA reviews when deemed necessary. The RSC also reviews ALARA design review and ALARA work reviews, which are described below.

21.3.2 ALARA Design Review Program

Each new facility or operation using radiation is subjected to reviews prior to commencement of any radiation work. LBNL follows formal review processes that culminate in reports such as SADs, AHDs, RWAs, or RWPs. Design and control measures are specified in the authorization basis for each facility or work process (SAD, AHD, RWA, RWP).

ALARA design review is incorporated into planning for new facilities to ensure that design features and administrative controls are selected and evaluated to meet regulatory requirements, and to keep radiation exposures to workers, the public, and the environment as low as reasonably achievable. The design objectives are to maintain accessible exposure rate levels to as far below 0.5 millirem per hour average, and maximum individual occupational exposures to as far below 20 percent of the applicable limits, as reasonably achievable. The primary methods used are engineering controls such as containment, ventilation, and shielding. Administrative controls are used only as supplemental methods of decreasing radiation exposures. Where the use of engineering controls is impractical, administrative controls and procedural requirements are used to maintain exposures ALARA. When appropriate, ALARA optimization methods for selecting design alternatives will be used if the collective exposure for a facility is expected to exceed 1 rem per year.

21.3.3 ALARA Work Reviews

ALARA work/experiment reviews assess radiological impacts, determine optimum radiological controls, track the effectiveness of controls, and document lessons learned. ALARA work planning is commensurate with the relative risks associated with the activity. ALARA reviews are carried out through the work authorization process. The review should be conducted for all operations, practices, and procedures that involve the potential for high individual or collective dose equivalent. The ALARA review will be documented via the Authorization Renewal documentation and/or Observation of Experiment Review (OER).

21.3.4 Dosimetry Reviews

RPG routinely reviews personnel dosimetry reports from the Dosimetry Office. These reports are provided monthly (nominally) and indicate the doses for all individuals who received positive dosimetry readings. This review helps ensure that ALARA measures are effective and allows any dose that appears not to be ALARA to be raised to the appropriate management personnel. Additionally, the Dosimetry Office notifies RPG of any individual dosimetry (internal and external) results that exceed predetermined alert-level thresholds as soon as the result is deemed reliable. When appropriate, the individual is contacted to verify that the dose received reflects the level of radiological work performed. When necessary, recommendations are made regarding the reasons for exposure and methods of exposure reduction.

21.3.5 ALARA Reports

RPG prepares periodic reports for RSC summarizing ALARA information and work activities. These reports may include information such as:

• Collective radiation exposure for the Laboratory and for individual facilities
• Information on individual radiation exposures exceeding predetermined dosimetry alert levels
• Results of dose investigations
• Results of ALARA reviews
• Reportable radiological occurrences
  

Information contained in these reports is provided to RPG staff, RCM, RSC, and other levels of Laboratory management, as needed.

RPG maintains a workplace monitoring program to ensure that contamination, dose equivalents, and the concentrations of airborne radioactivity in areas occupied by people do not exceed specified limits and that ALARA practices are followed. Radiation surveys must be performed by radiation users and RPG.

21.4 Radiation Protection Program

21.4.1 Group Organization

Radiation Protection Group (RPG)

The core RPG at Berkeley Lab, within EH&S, consists of Health Physicists (HPs), radiochemists, technologists, Radiological Control Technicians (RCTs), and administrative support staff. The following programs are carried out by RPG and have at least one health physics supervisor and one or more RCTs assigned.

The Technical Services Group (TSG) has Health Physicists, radiochemists, and technical specialists performing instrument calibration, dosimetry services, radioactive waste operation support, and radioactive material analyses.

Other programs carried out by RPG are Radiation Protection Training, Quality Assurance, Regulatory Affairs, X-Ray Authorization, and a program designed to ensure that radiation exposures are maintained as low as is reasonably achievable (ALARA).

Qualification by the American Board of Health Physicists or National Registry of Radiation Protection Technologists is encouraged. Some RPG personnel have certification by these organizations.

One-time projects, such as facility decommissioning, are supervised by permanent staff but may also use contract employees. Contract employees must have the same qualifications as permanent employees.

The RCM manages or provides technical oversight for the groups (RPG, TSG) that lead these programs and may adjust reporting relationships as needed. The RCM reports to the EH&S Division Director.

Additionally, Health Physicists and other technical staff perform duties in the areas of radiological environmental protection and radioactive waste disposal. These operations reside in other EH&S groups.

21.4.2 PAAA Program

DOE regulations contained in 10 CFR 820 implement nuclear safety enforcement requirements of the Price Anderson Amendment Act (PAAA). At Berkeley Lab, the PAAA Coordinator (PAAAC) reports directly to the Deputy Director of Operations. The RCM is responsible for reporting to the PAAAC any instances of actual or potential noncompliance with radiation protection requirements contained in 10 CFR 835, the Radiation Protection Plan (RPP), or this chapter.

21.4.3 Service Contacts

WHO TO CALL (subject matter expert)
WHO TO CALL (building)
EMERGENCIES: x7911
After-hours or weekend support: x5251
RPG (all services): x7652

21.5 Responsibilities

21.5.1 Radiation Workers

The term "radiation workers," as used at Berkeley Lab, is defined in the Glossary.

All radiation workers must:

• Follow the safety requirements outlined in their Authorization.
• Report unsafe conditions or abnormal radiological occurrences to their supervisor and to RPG.
• Ensure that their training qualifications are current and appropriate for the work activities and equipment that they use regularly, or that they may be expected to use in unusual situations.
• Consult their supervisor or RPG whenever questions arise.
• Maintain radioisotope journals, logs, and inventory summaries with accurate and timely data entries that reflect current work practices.
• Wear dosimetry properly, and participate in the bioassay program as required by their RWA. Workers must be prompt in exchanging dosimeters and providing bioassay samples.
• Monitor and minimize their own radiation exposure through good ALARA work practices.
• Monitor for contamination at every reasonable opportunity, and document surveys as required.
• Minimize waste. Keep waste segregated, properly stored, characterized, and documented. See PUB-3000, Chapter 20, Hazardous Waste Disposal, for additional guidelines.
• Strive to find and implement new "good work practices" to minimize dose, waste, and effluents.
• Practice good housekeeping in the laboratory to minimize accidents and mishaps.
  

21.5.2 Supervisors and Principal Investigators (PIs)

Supervisors and PIs must:

• Stop work when unsafe conditions exist.
• Report unsafe conditions or abnormal radiological occurrences to RPG.
• Ensure that all radiation work is within the scope of an approved authorization document.
• Promptly request new or amended RWAs when radiological conditions or changes are first identified.
• Ensure that radiation authorization (RWA, RWP, SSA, XA, etc.) safety requirements and conditions are being met.
• Ensure that radioisotope journals, logs, and inventory summaries are being properly maintained and reflect current work practices.
• Frequently monitor their employees' radiation doses and working environment in order to establish good ALARA work practices.
• Ensure that laboratory safety equipment and instruments are adequate for the work being performed.
• Schedule appropriate classroom and on-the-job training to keep worker qualifications current.
  

21.6 Radiological Work Authorization and Permit Programs

The system of controlling work in areas with actual and potential radiological hazards is based on the issuance of a written authorization or permit. RPG is responsible for issuing all authorizations and permits, except X-Ray Authorizations which are issued by the X-Ray Safety Officer.

RPG issues the following authorizations:

• Radiological Work Authorization (RWA)
• Radiological Work Permit (RWP)
• Sealed Source Authorization (SSA)
• Low Activity Source Authorization (LAS)
• Generally Licensed Source Authorization (GLA)
  

These programs are designed to keep personnel radiation exposures ALARA by providing administrative control of job activities involving radiation and by ensuring that adequate safety precautions are taken in areas with radiological hazards. Based on an analysis of the project's hazards, RPG will specify requirements such as dosimetry, bioassay, engineering controls, user and EH&S surveys, instrumentation, and protective equipment.

RPG will make routine assessments to determine compliance with the requirements and to assess laboratory radiological conditions. The PI of an RWA or LAS, work leader of an RWP, or source custodian of an SSA or GLA, is responsible for initiating corrective actions for any violation identified in the RPG assessment. A permit or authorization may be terminated by division management or by the RCM in response to repeated or serious violations of the requirements.

21.6.1 Radiological Work Authorization

The RWA program authorizes the use of radioactive material and radiation-producing machines, except x-ray machines. If only sealed sources are to be used, a Sealed Source Authorization (SSA) will be issued. The SSA is handled similar to the RWA process. See Section 21.6.3 for more information regarding sealed sources.

RWAs are issued for activities that are considered long-term projects under routine radiological conditions. The RWAs specify the quantitative limits on amounts of radioisotopes and the radiological conditions acceptable at the specified work areas. RWAs are classified, based on the degree of the associated hazards, as Class I, Class II, or Class III, with Class III designating the highest hazard class. An approved Class I or Class II RWA is valid for 18 months. An approved Class III RWA is valid for 12 months.

Before using radioactive material or a radiation-producing machine (except for an x-ray machine), the PI must obtain the approvals of the RCM and the cognizant division director.

The following sections describe the RWA process. More details are provided in EHS Procedure 707, Radiological Work Authorization Program.

RWA Application

When a new RWA or major RWA revision is needed to perform radiological work, the PI should prepare an application to request RPG to issue an RWA.

Applications are to be submitted to the RPG Group Leader (M/S 75B-101) or to the assigned Health Physicist (M/S 75B-101). The receipt of the application will be acknowledged via telephone or e-mail to the person initiating the memo. A meeting will be scheduled by the RWA Health Physicist to review the draft RWA with the PI and evaluate the facilities. A minimum of two weeks is required to establish a new RWA.

The following information is to be either provided directly or referenced (and attached) on the memo. See EHS Procedure 707 for further details.

Review and Processing of RWA Applications

After an application is received by RPG, or when a renewal is required, the RWA Health Physicist conducts a detailed review of the proposed project to determine the appropriate precautions, limitations, and ALARA practices necessary to ensure both good and safe work practices. This review must be followed by a personal interview with the applicant and an inspection of the proposed workplace(s).

Items to Evaluate. The RWA Health Physicist and the Radiological Control Technician should evaluate the items listed in Table 4-1 of EHS Procedure 707.

Precautions and Limitations. All precautions and limitations identified during this review must be appropriately documented in the RWA. Documentation resulting from this section should be appropriately labeled and filed in the RWA file.

Sewer Disposal Program. Water-soluble (or readily dispersible) liquids may be disposed of into the sewer system with adequate flushing, within certain limits described in EHS Procedure 707.

Training

All personnel must have training commensurate with radiation hazards prior to performing work authorized by an RWA. EH&S Radiation Worker training is generally required. (See Section 21.11.1, Radiation Safety Training.) Principal Investigators must ensure that on-the-job training (OJT) addressing the unique hazards of the authorized work is performed and documented.

Amendments to an RWA

Changes to RWAs must be classified as either minor or major amendments. Minor amendments may be accomplished by "pen and ink" changes to the original RWA. Major amendments require the generation of a new RWA and require the same review and approval process as a new RWA.

Examples of minor amendments include:

• Addition/deletion of radiation workers
• Administrative changes that do not affect the type of work process being performed or the work process
• Reduction in isotope use
• Changes to personnel training requirements

Examples of major amendments include:

• Changes in PI, at the Health Physicist's discretion
• Changes/addition of isotopes above the LAS quantities
• Changes in authorized work locations, at the Health Physicist's discretion
• Significant changes to existing protocols or addition of new protocols
• Increase in use or possession limits

Major Amendments

Major amendments to an RWA should be initiated by the responsible PI, by sending a memo detailing the changes to the RWA Health Physicist.

Proposed major amendments will be evaluated by RPG for their impact on the existing hazards class and safety requirements. If the change increases the project to Class II or III, then an Observation of Experiment Review (OER) is required during the first use of the radioisotope.

The RWA Health Physicist should review the request from the PI, draft the revised RWA, and expeditiously route the document for approval and distribution, as required by Sections 4.6 and 4.7 of EHS Procedure 707.

RWA radiation workers are required to review and sign the new RWA for major amendments to an RWA.

If major amendments to the RWA affect the way researchers do their work, the RWA Health Physicist informs the radiation workers of these changes.

Minor Amendments

RPG staff may direct administrative changes that do not affect the type of work process being performed or the work process. The responsible PI should request all other minor amendments in writing. Reasons for the change should be clearly noted in the RPG files.

Minor amendments should be made in ink to the original RWA in the RPG file. The RWA Health Physicist must approve and initial all changes. A copy of the revised original must be filed in the research project's radioisotope journal (RIJ).

Termination or Moving of a Project (RWA)

To terminate an RWA, the PI must notify RPG in writing at least 30 days before the anticipated termination. The PI is responsible for disposal of all radioactive material authorized by the RWA. The RWA terminating process requires that the PI complete the following:

• Return of personal dosimeters, instruments, and other RPG items
• Requisition and removal of radioactive waste
• Removal or transfer of radioactive materials
• Submission of terminal bioassay, if required by the RWA

The RPG RCT must complete the following:

• Terminal surveys
• Proper de-posting of radioactive material storage and use areas
  

The project is placed in terminated status in the RADAR database following the completion and review of the above. An RWA may also be placed on inactive status if work has been temporarily suspended, but is expected to resume. See EHS Procedure 707, Section 4.14.

Procurement of Radioisotopes

Only radioactive material authorized by an approved RWA, SSA, or LAS may be procured. See Section 21.11.3, , Radioactive Materials Safety, Procurement of Radioactive Material.

Records

Radioisotope Journal

Each project group must maintain a radioisotope journal (RIJ), or equivalent, in which pertinent records are filed in a readily retrievable manner. This RIJ must be accessible to all persons who work with radioactive material under the project. The RIJ must also be available for inspection at any time during normal working hours, and the project staff should know where such records are kept. The RIJ must contain all relevant documents, or reference the location of documents, and must be kept in one or more volumes at one location. RPG will furnish RIJ binders.

The RIJ must include, but is not limited to, the following records. See EHS Procedure 707 for further details.

• Current Authorization
• Radiation surveys (see Section 21.10.2)
• Daily usage logs
• Training
• Incident reports
• Miscellaneous
• Quarterly inventory report
• RWA performance evaluation (see Attachment A)
  

21.6.2 Radiological Work Permit

RWPs are issued for short-term or nonroutine projects that, upon review by RPG, require measures to protect personnel, the public, or the environment from radioactive contamination or radiation exposure. The RWP document informs workers of the radiological controls and entry requirements for a specific work activity and is valid only for the duration of the project. The RWP must be completed, approved, and posted prior to performing any work where radiological concerns exist.

Work cannot begin until an approved RWP is in place.

RWP Application

To initiate an RWP, send a written request with the following information to the RWP Program Manager:

1. Name and employee number of the Work Leader and workers assigned to the project.
2. A description of the project, including description of the hazards, radiological and other, that could be encountered. If the Work Leader does not have this information, the RWP Program Manager will work with the Work Leader to obtain it.
3. Dates that the work is expected to begin and end.

Upon receipt of the RWP request, the RWP Program Manager will review the information to determine the hazard class of the RWP.

Determining the Hazard Class (as described in EHS Procedure 705, Radiological Work Permit Program)

All work performed under an RWP falls into one of three categories: low hazard (Class I), moderate hazard (Class II), and high hazard (Class III). These hazard levels are defined below. See Section 21.13, Glossary, for the definitions of all terms listed in bold below.

• Low-level radiological work (less than the 10 CFR 835 App. D limits) with minimal hazard will be Class I. Hands-on work with loose radioactive material or work in a Contamination or Radiation Area is prohibited with a Class I RWP.
• Any work in a Radiation Area or Contamination Area (less than 100 times the 10 CFR 835 App. D limits) will be Class II.
• Any work in a High Radiation Area, High Contamination Area (greater than 100 times the 10 CFR 835 App. D limits), or Airborne Contamination Area will be Class III.
  

The hazard class may be elevated to more conservative levels if it is deemed appropriate for the nature of the work.

Review and Processing of RWP Applications

Specifying Controls

The RWP Program Manager determines the specific controls required for the RWP, depending on the nature of the work. In general, however, the following items may be required. (See EHS Procedure 705 for details of these items.)

• Personal protective equipment
• RCT coverage
• Posting and barriers
• Surveys
• Air sampling
• Equipment release, storage, and transfer
• Stay time restrictions and hold points
• External dosimetry
• Bioassay
• Training
• Emergency procedures
• Work plan
  

Approving an RWP

The RWP Program Manager routes the final RWP for approvals, which are indicated by signatures. The hazard class of the RWP determines who approves the RWP. Regardless of the hazard class, all RWPs must be reviewed and signed by the Facilities Director (if applicable) and the Work Leader to ensure proper notification and compliance.

The following approve Class I RWPs:

• RWP Program Manager
• RPG Group Leader
• Radiological Control Manager
  

The following approve Class II RWPs:

• The same approvers as Class I RWPs
• Environmental Services Group NESHAPS Coordinator
• Radiation Safety Committee Chair
  

The following approve Class III RWPs:

• The same approvers as Class II RWPs
• Radiation Safety Committee (RSC)
  

Issuing an RWP

When an RWP has been approved, copies will be made available to the Work Leader and the RCT. A copy of the RWP must be maintained at the work site. The original RWP must be kept in the RPG RWP files.

Before beginning work under the RWP:

• The RWP Program Manager must ensure that all workers listed on the RWP have current required training.
• The RWP Program Manager and Work Leader must ensure that all hazardous materials have been removed from the work area or have been properly contained, packaged, disposed of, or otherwise made safe to handle, and that proper documentation is filed in the RWP.
• A pre-job briefing is required for all personnel working under the RWP before beginning work. This briefing should be performed such that all personnel have sufficient time to review work plans and procedures. The RWP RCT and/or RWP Program Manager or designee will conduct the briefing. Subjects covered in the pre-job briefing must include the hazards that could be encountered in the work, the requirements stated in the RWP, and emergency procedures. For Class III RWPs, the RWP Program Manager or designee should also be present.
• All personnel must have successfully completed the training required by the RWP prior to signing the RWP.
• At the completion of pre-job briefing, the workers sign the RWP, which signifies that the workers have completed required training and understand the requirements of the RWP.
• A copy is made of the signed and approved RWP and is maintained at the work site by the Work Leader and RCT.
• The RWP Program Manager or designee files the original approved and signed RWP in the RPG RWP file.
  

Training

All personnel must have training commensurate with radiation hazards prior to performing work authorized by an RWP. EH&S Radiation Worker training is generally required. (See Section 21.11.1, Radiation Safety Training.)

Amendments to RWP

Minor Amendments to an RWP

Minor amendments to an RWP are defined as changes that do not increase the potential for release of or exposure to radioactive material. Examples of minor amendments include the following:

• Administrative changes that do not affect the type of work being performed or the work process
• Changes to room structure, personnel, or monitoring equipment, if the safety of workers, the public, and the environment is not compromised
  

The RWP Program Manager will determine if a requested change is a minor change. Minor changes are added to the original RWP with the current date and initials. A copy of the page with the change must be provided to the RCT and/or Work Leader.

Major Amendments to an RWP

A new RWP is required when there is a major amendment to any of the following:

• Hazard level.
• Scope of work.
• Primary work location: primary work locations are defined as locations where a majority or key element of the work is performed, and there is a significant risk of yielding the radioactive contamination or radiation exposure outlined in the RWP. Primary work locations are listed on the RWP.
  

Extending an RWP

The RWP Program Manager must verify the status of the project two weeks before the expiration date. If the project is not complete, the expiration date may be extended.

Minor Amendments for Extensions

Before extending an RWP, the RWP Program Manager must review the radiological hazards to determine if there are any minor amendments.

• If minor amendments are required in addition to the extension, the RWP Program Manager makes the amendments and adds the revised RWP and extension form to the RWP. The old RWP must have "Superseded" written across the superseded pages, with the RWP Program Manager's initials and date.

The RWP Program Manager determines whether an additional pre-job briefing is required for an RWP extension. If an additional pre-job briefing is performed, all qualified personnel must re-sign the "Authorized Personnel" section of the RWP.

Extension Approval

An extension for a Class I RWP is approved in the same manner that a new RWP is approved. See Approving An RWP. The RCM may sign for the Radiation Safety Committee Chair on Class II RWP extensions. The Radiation Safety Committee Chair may sign for the Radiation Safety Committee on Class III RWP extensions.

Issuing an Extension

An extension is issued in the same manner a new RWP is issued and may be granted for up to one year.

Oversight

Throughout the course of the RWP work, RPG staff will document the radiological conditions and the conduct of work in accordance with the terms of the RWP. This information will be documented in the master RWP file.

Closeout

At the conclusion of the work activity, RWP closeout surveys and audits will be completed by RPG personnel. All surveys, air sampling, contamination, incidents, dosimetry results, worksite status, audits, violations, and lessons learned will be documented in the master RWP file.

21.6.3 Sealed Source Authorization

A sealed source is radioactive material encapsulated or plated in such a way that it will not be released under normal conditions. RPG is responsible for approving all procurement and use of radioactive sealed sources. EHS Procedure 711, Sealed Source Authorization Program specifies the appropriate procedures to help ensure worker safety when working with or near sealed radioactive sources, including requirements for accountability, procurement, receipt, use, storage, inventory, and leak testing. A list of compliance violations can be found in Appendix B.

Administrative controls for sealed-source use have been implemented using the RWA concept. If no unsealed materials are authorized, a Sealed Source Authorization (SSA) is used. If both sealed and unsealed materials are authorized, an RWA is used. Sources exempt from NRC licensing or sources generally licensed by the NRC, known as Generally Licensed Sources, may require authorization by an SSA or a Generally Licensed Source Authorization (GLA) at the discretion of the Sealed Source Program Manager. This authorization may be required even if the manufacturer's documentation indicates that a specific site license is not required.

SSA Application

Requests for an SSA must be initiated through RPG and made in the same manner as for an RWA. Section 21.6.1, Radiological Work Authorization, RWA Application, describes the proper application process.

Source Custodian Requirements

Each sealed source requiring an authorization must be assigned to a source custodian who will be responsible for it. Source custodians will be LBNL employees unless otherwise authorized in writing by the RCM. An SSA, RWA, or GLA will be issued to the source custodian; it will list all sources in the custodian's possession, their use and storage locations, and all precautions and conditions of use. (See Section 21.4, Radiological Work Authorization and Permit Programs, for more information about the RWA process.)

Procurement of Sources

Only radioactive material authorized by an approved RPG-issued authorization may be procured. See Section 21.11.3, Radioactive Materials Safety, Procurement of Radioactive Material. If possible, an existing LBNL source should be used. If a new one is to be purchased, a new or amended RWA, SSA, or GLA must be issued.

Transfer of Sources

Any radioactive source coming on site must be delivered to the EH&S Transportation Office, as with other radioactive material. When the source arrives, RPG will test it for integrity, assign an inventory number (sealed-source identification number), and enter it into the radioactive material database. The source custodian will sign the RWA, SSA, or GLA, accepting responsibility for the source.

If a source is to be moved to a use or storage location not on the RWA, SSA, or GLA, RPG must be notified to amend the authorization and assist in the transfer.

All offsite transfers must be through RPG. A leak test is required prior to transfer.

Source Possession Procedures

Sources must be kept in properly labeled, secured, shielded areas. Conditions of use and storage are specified in the RWA, SSA, or GLA, and in EH&S Procedure 711. It is the responsibility of the source custodian to make the source available to RPG for semiannual leakage testing. Any source found to be leaking over limits must be repaired or disposed of through the Hazardous Waste Handling Facility (HWHF). Note: Wear gloves and use caution when handling fragile sources. Notify RPG if there is any suspicion of source damage.

Source custodians are responsible for maintaining the integrity of sealed sources. When a new source is purchased, information from the manufacturers regarding handling, useful lifetime, etc., must be given to RPG. The source custodian must ensure that fragile sources are checked for leakage after each use or transfer and notify RPG of any contamination detected. A sealed source log that lists the location and current user of each source must be maintained by the custodian. An entry must be made whenever the source is removed from storage. Sealed sources must not be stored with unsealed radioactive materials. When a source is no longer needed, RPG must be contacted. If the RCM determines that the source will not be kept for future use, the custodian must dispose of the source through the HWHF.

Training

All personnel who use sealed radioactive sources must have training commensurate with radiation hazards. EH&S Radiation Worker training is generally required. (See Section 21.8, Radiation Safety Training.) Sealed-source custodians must ensure that on-the-job training regarding the unique hazards of sealed sources is performed and documented. Disposing of unneeded sources requires waste generator training. Contact the project's Waste Generator Support Specialist for assistance.

21.6.4 Low Activity Source Authorization (LAS)

Unsealed isotopes possessed or used at or below the limits specified in RPG Procedure 707, Radiological Work Authorization Program, do not require an RWA. The material is authorized under a Low Activity Source authorization (LAS).

The project may possess no more than ten such quantities. Each laboratory (room) may have no more than one project using LAS quantities.

LAS Application

Application for the LAS authorization is made by the responsible researcher via e-mail or direct mail to the Radiation Protection Group (MS75B-101), describing the following: materials to be used, proposed use, work/storage areas, delivery point information, names of users, and waste disposal and survey needs.

Review and Processing of LAS Application

The LAS authorization is formalized in a document that is sent to the applicant; the applicant retains a copy and returns a signed copy to RPG. The authorization is for a term of approximately 12 months. Near the end of the authorization period, RPG will call the project to review the continuation of the LAS authorization for another term.

LAS Area Posting and Labeling

Work with LAS-level radioactive material must be conducted within a posted controlled area. Waste is to be disposed of in properly labeled radioactive material waste containers.

Training

EHS0405, General Employee Radiological Training (GERT), is required for all LAS users.

21.6.5 Generally Licensed Source Authorization (GLA)

Sources exempt from Nuclear Regulatory Commission (NRC) licensing, or sources generally licensed by the NRC, known as Generally Licensed Sources, may require authorization by an SSA or a Generally Licensed Source Authorization (GLA) at the discretion of the Sealed Source Program Manager. This authorization may be required even if the manufacturer's documentation indicates that a specific site license is not required. This is due to differences between NRC and DOE regulations concerning the control of radioactive material.

Examples of generally licensed sources include, but are not limited to:

• Internal calibration sources in LSC machines
• Static eliminators
• Gas chromatographs
• Electron capture devices
  

These sources are usually an integral part of a machine or apparatus and are not handled directly.

21.6.6 Control and Accountability of Radioactive Material

Inventory Control and Quarterly Reports

Radioactive materials must be controlled at all times. Each PI is responsible for maintaining accurate records of the amount and type of radioactive material in storage and use in their laboratory. Each quarter, the authorized projects are provided with a quarterly inventory report from RPG which details the radioactive material delivered to the project in the past quarter as well as a list of stored radioactive stock. The project must promptly update the report, noting the location of the material and whether it is still in use, in storage, or disposed of as radioactive waste.

Sealed radioactive sources must be controlled in a locked cabinet or room. The source must be signed out and the use location must be tracked. The RPG group performs inventory audits every six months for exempt and accountable sealed sources.

Nuclear Material Management and Safeguards System (NMMSS) Program

Nuclear materials are materials that DOE has identified as requiring special controls to prevent their loss or theft. They are ⁶Li, ²³⁷Np, ²⁴¹Am, ²⁴³Am, ²⁴⁹Bk, ²⁵²Cf, deuterium, tritium, and all isotopes of curium, plutonium, thorium, and uranium. The NMMSS Program at Berkeley Lab is outlined in RPG Procedure 740 and is managed by the RPG Nuclear Materials Representative.

Physical Security of Radioactive Material

Radioactive materials that are not being used (exclusive of material that has become radioactive by bombardment with neutrons or charged particles, called "induced radioactive material," covered separately below) must be stored securely in an area designated as an RSA. Storage of radioactive material within an RMA is discouraged, but may be allowed by RPG for special circumstances. Examples of suitable storage areas include:

• The Pit Room (70-147A) storage facility operated by RPG
• A building or room locked during off hours containing an RMA or RSA
• Lockable, fire-retardant Berkeley boxes or air-filtered cabinets designed to be earthquake-resistant

Unsuitable storage areas include bench tops, desk drawers, fume hoods, and wooden cabinets or lockers.

Details of the LBNL site security plan are included in the Lab's Site Safeguards and Security Plan.

21.7 X-ray Authorization (XA)

21.7.1 General

This section applies to electronic devices under the administrative control of LBNL that are designed to produce X-rays beyond a contiguous vacuum.  It is directed towards the use of X-rays as an analytical tool; it is not meant to apply to the design and construction of prototype X-ray equipment.  Once put into routine use, any such equipment will be covered by the LBNL X-ray program.  Other X-ray radiation producing machines are also addressed.

The primary objective of the LBNL X-ray safety program is to ensure that exposure to radiation from X-ray machines is as low as reasonably achievable (ALARA).  The primary means to achieve this objective is by engineered controls.  To the extent possible a combination of interlocks, sensors, barriers, shielding, warning lights and tones, and area monitors are used.  For analytical X-ray machines, this means that only enclosed beams are allowed for routine use.  The expected exposure for the routine users and non-users at LBNL from analytical X-ray machines is below the minimum reportable dose of an optically stimulated luminescence (OSL) dosimeter.  The program is based on the X-ray safety guidance provided by ANSI N43.2 and N43.3 for analytical X-ray machines, NCRP 102 and 49 for medical X-ray machines, and Title 21 of the Code of Federal Regulations (21CFR), Chapter I, Subchapter J for cabinet X-ray machines and irradiators.  Medical machines not being used for human use at LBNL are considered industrial equipment and must be operated fully enclosed, except when granted a variance by the Radiation Safety Committee (RSC). All X-ray operations at LBNL must be reviewed and approved by the LBNL X-ray Safety Officer (XSO) or backup XSO.

Devices Beyond the Scope of this Program

X-ray machines are a subset of a much broader set designated as radiation-producing machines.  It is recognized that it is easy to generate X-rays either intentionally or adventitiously.  Any device that combines high voltage and a metal target in a contiguous vacuum can cause X-rays when a current flows and users should be alert to this possibility.

Therefore, any electronic device that could produce an X-ray field should be brought to the attention of the XSO.  An evaluation of the hazards will be performed by the XSO and controls will be implemented on a case-by-case basis to achieve the objectives of X-ray safety at LBNL.

For equipment designed and built at LBNL, it is advisable to inform the XSO early in the design process so that safety needs may be predicted to the extent possible and protective measures employed as an integral part of the design.  The goal will be to make the device as intrinsically safe as is reasonably achievable with no detectable X-ray fields outside of the contiguous vacuum of the X-ray source.  If this goal can be achieved, the device will not be considered a radiation-producing machine and no additional radiation safety controls will be required.
Electron microscopes, ion implanters, Electron Spectrometers for Chemical Analysis (ESCA), Photoemission X-ray Spectrometers, or X-ray Photoelectric Spectrometers (XPS) machines do not emit X-rays beyond the contiguous vacuum as a part of their design function and are usually designed to prevent such emissions on an incidental basis as well.  Thus, they are not usually considered radiation-producing machines at LBNL.  If such a device is suspected of emitting X-rays, it must be brought to the attention of the XSO, who will evaluate it and determine what provisions must be made for safe use.

Any radiation-producing machine that can directly or indirectly produce ionizing radiation outside a contiguous vacuum, such as neutron generators, Vann de Graaff accelerators, and ion sources, must be reviewed by a Radiation Protection Group (RPG) health physicist and properly authorized in accordance with section 21.6.1 or 21.6.2 of this chapter.

21.7.2 Responsibility

Specific Responsibilities

Radiological Control Manager (RCM)

The RCM has overall responsibility for the X-ray safety program, including specific implementing responsibilities detailed in EH&S Procedure 735, X-ray Machine Authorization Program.

X-ray Safety Officer (XSO) and/or Backup XSO

The X-ray Safety Officer is responsible for managing and executing the X-ray safety program, including, but not limited to, the following:

• Maintains the LBNL X-ray safety program.
• Reviews and provides technical advice and safety approval for all operations that have the potential to produce X-rays other than from isotopic sources.
• Maintains an inventory of all X-ray machines at LBNL.
• Maintains required regulatory records.
• Submits to the Radiation Safety Committee requests for variance.
• Investigates any suspected incidents or accidents.
• Provides EH&S 410, X-ray Radiation Safety Training and EH&S 401, Radiation Safety Retraining.
• Approves the use of an escort in lieu of training.
• Communicates with Engineering Division to ensure that a qualified engineer is assigned responsibility to perform X-ray system safety analyses.

Other specific implementing responsibilities are detailed in EH&S Procedure 735, X-ray Machine Authorization Program.

X-ray System Supervisors (XSSs)

The XSS must provide detailed written information to the XSO to assist in preparation and implementation of the XA.  The XSS must contact the Engineering Division and request an Electrical Engineer to perform a system safety analysis prior to initial machine use and issuance of an XA.  The XSS must ensure that the XA requirements and limits are adhered to and that good work practices are followed.

The XSS must:

• Notify the XSO of proposed X-ray acquisitions, disposals and proposed changes to the X-ray systems.
• Complete EH&S 400, Radiation Safety Fundamentals and EH&S 410, X-ray Radiation Safety training (EH&S 401 is retraining).
• Complete EH&S 401 retraining every two years following completion of initial training.
• Submit new X-ray radiation worker names to the XSO for training and addition to the XA.
• Provide fundamental X-ray safety training using the training materials and exam provided by the XSO. Maintain a file of successfully completed X-ray user exams (80% score required for passing).
• Provide machine specific on-the-job training (OJT) to X-ray users and X-ray radiation workers, documenting this training and filing the documentation in the X-ray Radiation Journal (XRJ) provided by the XSO.
• Post the current users' list, including expiration date, for X-ray users.
• Ensure that only personnel on the posted users' list and whose training has not expired are allowed to use the X-ray machine/s under their supervision.  For X-ray machines equipped with Prox Key control, this is assured by submitting names and training dates of X-ray users for entry into the LBNL access control computer.
• Ensure that the provisions of the XA and those herein are implemented.
• Provide an account number for an X-ray systems safety analysis.
• Notify the XSO of proposed changes in X-ray use.
• Ensure that an Equipment Movement Record is filled out and the XSO is notified if any X-ray equipment is relocated.
• Perform interlock testing at the frequency and in the manner specified in the XA.
• Notify the XSO 24 hours in advance of allowing service personnel, who are not specifically listed on the XA, to work on an energized X-ray machine.
• Seek XSO approval prior to allowing escort in lieu of training.
• Ensure that manufacturers or outside service representatives are not working in an unsafe manner or causing exposure to LBNL employees or the general public.  The XSO, or designee, can be made available to assist with this assurance.

Other specific implementing responsibilities are detailed in EH&S Procedure 735, X-ray Machine Authorization Program.

X-ray Radiation Workers

X-ray radiation workers are:

• those with administrative responsibilities, such as the XSS, assistant XSS(s),
• personnel authorized to train X-ray users on the use of X-ray machines,
• those who are authorized to use the interlock override capability of the machine (if so equipped) and may thus operate the unit temporarily as an open beam unit if needed,
• maintenance personnel who perform maintenance on the X-ray enclosure, interlock system, or any portion of the machine that may affect personnel safety, or
• maintenance personnel who perform maintenance on the X-ray machine while the X-ray machine is producing X-rays (e.g. performing alignments on X-ray optics and detectors).

X-ray radiation workers must ensure that the XA requirements and limits are adhered to and that good work practices are followed.  X-ray radiation workers must:

• Complete EH&S 400, Radiation Safety Fundamentals and EH&S 410, X-ray Radiation Safety training (EH&S 401 is retraining),
• Be designated in the XA,
• Complete OJT training,
• Assist XSS in providing and documenting OJT training to routine system users, and
• Abide by all requirements and precautions of the XA.

Other specific implementing responsibilities are detailed in EH&S Procedure 735, X-ray Machine Authorization Program.

X-ray Users

X-ray users are those individuals that may operate an X-ray machine while the X-ray machine is fully interlocked and enclosed within an enclosure that prevents any individual from placing any body part into an area with a dose rate in excess of 0.5 mrem/h at 5 cm from the enclosure.  It is expected that the majority of X-ray users at LBNL will fit into this category.  Any authorization for other than routine use must be specified in the X-ray Safety Document.  X-ray users must:

• Know the safety requirements that apply to their specific X-ray machine.
• Complete LBNL General Employee Radiological Training (GERT) and fundamental X-ray safety training and machine-specific OJT training given by the XSS or designated X-ray radiation worker, as designated in the XA.
• Complete retraining whenever the XA is changed (required for any change in setup or operation) or every two years, whichever is less.
• Know and adhere to control requirements established herein.
• Immediately report any deviations from established X-ray safety procedures and controls to the XSS, XSO, or RCM.

Other specific implementing responsibilities are detailed in EH&S Procedure 735, X-ray Machine Authorization Program.

Division Directors

Division Directors, by virtue of the delegation of responsibility for all aspects of environmental health and safety through line management, must:

• Ensure that no X-ray machine is acquired, fabricated, relocated or disposed of by division personnel without prior notification to the XSO.
• Ensure that no X-ray machine is energized by division personnel without an approved XA, system safety analysis, assigned XSS, and required training and prescribed dosimetry.
• Ensure that all X-ray machines approved for operation are operated within the provisions of that approval and this document.

Manufacturers or Outside Service Representatives

Manufacturers or outside service representatives, used for installation or service of X-ray machines at LBNL, are responsible to their parent organization unless their actions are done in such a way as to cause X-ray exposure to LBNL personnel or the general public. Manufacturers or outside service representatives that must perform work on an energized X-ray machine must:

• Provide proof for completion of equivalent X-ray radiation safety training within the previous two years.
• Complete LBNL GERT.
• Abide by the precautions and requirements of the XA.

Electrical Engineer Performing a System Safety Analysis

Electrical Engineers assigned by the Engineering Division to perform a system safety analysis of an X-ray machine must:

• Perform, with assistance as needed and appropriate, a system safety analysis at the request of the XSO or an XSS.
• Prepare, with assistance as needed and appropriate, the written system safety analysis report, including the routine interlock Testing Protocol Checklist.
• Approve, sign and submit the report to the XSO.

21.7.3 X-ray Machine Safety Documents

X-ray Authorization (XA)

An XA is an authorizing document renewable at 18 month intervals in conjunction with a visit by the XSO.  The XA is prepared by the XSO from information presented by the XSS in the XA application.  The XA must contain at least the following:

• The name of the person responsible for the unit (XSS)
• A list of X-ray radiation workers
• An emergency or problem call list
• Equipment descriptions and parameters
• Descriptions of safety features
• Specific operating procedures
• Specific alignment procedures, as applicable
• Specific safety precautions and requirements
• Completion date of the system safety analysis and a summary of the findings
• Specific radiation survey requirements and interlock testing interval

Approval signatures as specified above.

XA Application

When a new XA or a major revision to an existing XA is required, the XSS should prepare an application to request the XSO to prepare or change the XA.

Applications are to be submitted to the XSO or backup XSO (M/S 75B-101). The receipt of the application will be acknowledged via telephone or e-mail to the person initiating the memo.  A meeting will be scheduled by the XSO to review the draft XA with the XSS and evaluate the facilities.  For new installations, the system safety analysis must be completed first, after which a minimum of two weeks is required to establish a new XA.  The request for a new XA or modification of an existing XA must contain at least the following:

• The name of the person responsible for the unit (XSS)
• A list of proposed X-ray radiation workers
• An emergency or problem call list
• Equipment descriptions and parameters
• Descriptions of safety features
• Specific operating procedures
• Specific alignment procedures, as applicable.

An XA application guide is available from the XSO to assist in preparing the XA request.  Contact the XSO at extension 2278 to obtain a copy of the guide.

The XA application is used to prepare the XA.  There is no requirement to review or revise the XA application after initial submission, unless requested by the XSO.

21.7.4 System Safety Analysis

All X-ray machines must undergo a system safety analysis as follows:

• For new units, before operation,
• for working units, upon modification involving the interlocks, and
• for out-of-service units, before being brought back into service.

A system safety analysis must be performed by an electrical engineer and must consist of at least the following:

• A description of the X-ray machine under review, including warning indicators, interlocks, and all applicable personnel safety systems.
• Identification of modifications to the safety systems, if any.
• Verification, update, or production of schematic diagrams of the safety systems.
• Assessment of potential equipment failure modes and their possible consequences, with emphasis on the failure modes of interlocks and other safety systems.
• Review/preparation of the detailed protocol for routine maintenance testing of safety devices.
• A determination of whether or not the interlocks and warning indicators are failsafe as defined in this procedure.
• Preparation of a written report of the findings of the analysis, together with recommendations for action, if any.  The written report must make a clear statement regarding the fail-safe and redundancy nature of all interlock systems.  The original report must be signed by the electrical engineer assigned to perform the system safety analysis. The signed system safety analysis must be reviewed and signed by the XSO or backup XSO who will distribute copies to the XSS.  Original system safety analyses documents must be filed in the appropriate RPG XA file.

Engineering Division Management, in consultation with the XSO, appoints the electrical engineer assigned to perform system safety analyses for an indefinite period.  The funding for a system safety analysis is provided by recharge to the owner of the X-ray machine.  Owners must be prepared to provide an LBNL account number for this service.

21.7.5 Interlocks and Indicators

An interlock system can provide safety by ensuring that humans and hazards do not contact each other.  Interlock systems on X-ray machines must be failsafe.  The interlocking system is failsafe if the system is designed such that all realistically anticipated failures of indicators or safety components result in a condition in which personnel are safe from exposure to radiation.  For example: If a light indicating “X-ray On” fails, the production of X-rays shall be prevented, or if a shutter status indicator fails, the shutter shall close.  This usually means that the interlocking system is comprised of two independent interlock chains that employ two different methods to stop X-ray emissions.

If an X-ray machine does not incorporate two completely independent interlock chains that utilize two independent methods for stopping the production of X-rays, then the XSS must propose an alternative that provides a comparable level of safety and demonstrates that the X-ray machine is failsafe and request a variance.  The proposed alternative must be reviewed and the request for a variance approved by a subcommittee of the LBNL Electrical Safety Committee (ESC).

All X-ray machines must meet the requirements in Section 21.7.7 of this chapter.

21.7.6 Override of X-ray Safety System Interlocks

Interlocks and indicators must not be bypassed or overridden for any reason unless specifically authorized in the XA.  Only specifically authorized and designated personnel may bypass or override an interlock or indicator.  Such individuals must be specifically identified in the XA.

Overriding of interlocks is never allowed for routine use.

21.7.7 X-ray Machine Design

All X-ray machines authorized by an XA must meet the following minimum requirements unless a variance is requested by the XSS and approved by the appropriate committee or subcommittee.

Enclosure

The X-ray machine must be located within an enclosure that is designed in such a way that it prevents any individual from placing any body part into a primary beam within the enclosure when the enclosure is fully interlocked.

An X-ray machine that utilizes architectural structures, other than the floor on which it may be placed, as part of the X-ray enclosure (e.g. a CT scanner enclosed within a room) will be considered an enclosed X-ray machine if all access points, such as doors and windows, are fully interlocked in accordance with this procedure or permanently secured in a closed position with tamper resistant fasteners.  Prior to permanently securing doors and windows in a closed position, the appropriate EH&S personnel, such as Fire Marshal, must be consulted.  Personnel occupancy is not allowed within such enclosures during routine operations.

All enclosures must be designed to prevent access to the primary X-ray beam by means of interlocks or in a manner that requires tools for access.

Shielding

X-ray enclosures must be shielded such that the dose rate at any accessible region 2 inches (5 cm) from the outside surface of the enclosure does not exceed 0.5 mrem in any 1 hour.

If an enclosure is designed with openings, such as an open top or penetration labyrinth, the enclosure must be shielded such that the dose rate at any area accessible through the opening, without the use of tools (e.g. a ladder), does not exceed 0.5 mrem in any 1 hour.

Safety Shutters

All X-ray machines designed such that an individual can enter the enclosure without activating an interlock override/bypass mode, while the X-ray machine is energized and producing X-rays, must be equipped with an automatic safety shutter on each X-ray port.

Safety shutters must be designed such that the shutters’ position can be manipulated remotely from outside the enclosure, as well as automatically by the interlock system.  X-ray machines with automatic shutters do not require an interlock bypass/override mode of operation to gain access to the enclosure if:

• The shutters are controlled by an interlock system that automatically prevents access to the primary beam by ensuring that the shutters are closed or by automatically closing the shutters when an enclosure door or panel is opened and


• The dose rate at any accessible region 2 inches (5 cm) from the outside surface of the X-ray tube with the shutters closed does not exceed 0.5 mrem in any 1 hour.

X-ray machines that are equipped with a manual safety shutter or where the dose rate at any accessible region 2 inches (5 cm) from the outside surface of the X-ray tube with the shutters closed exceeds 0.5 mrem in any 1 hour will be treated as if no shutter exists.  Such X-ray machines must require the activation of an interlock override/bypass mode to gain access to the enclosure if the X-ray machine is energized and producing X-rays.

Warning Indicators

All X-ray machines must be equipped with at least two independent methods to verify that X-rays are on.  One, but not both, may be a current (mA) meter.  Failure of one indicator must not result in the failure of the second indicator.  At least one indicator must be an illuminated warning lamp with the words “X-ray On” or similar wording.  The illuminated “X-ray On" indicator must be part of the interlock chain and fail-safe. A failure of this warning indictor must prevent the generation of X-rays.

All X-ray machines equipped with an interlock bypass/override system must be equipped with an audible alert that can be heard from within the enclosure and remains activated until the bypass/override mode is disabled.

All X-ray machines equipped with an interlock bypass/override system should be equipped with a visual alert, such as a strobe or beacon that can be seen from within the enclosure and remains activated until the bypass/override mode is disabled.

All X-ray machines equipped with safety shutters and an enclosure designed to allow access while the X-ray tube is generating X-rays must be equipped with a mechanical shutter position indicator or a failsafe electronic shutter position indicator for each shutter.  Each shutter position indicator must be clearly visible from all entry points to the enclosure.  In addition to the mechanical shutter position indicator, electronic shutter position indicators are highly recommended.

Interlocks

All doors and any portion of an enclosure that can be opened without the use of tools must be equipped with two interlocks that disable the X-ray machine if the enclosure is opened while the X-ray machine is producing X-rays and a safety shutter is open, unless a bypass/override mode has been activated.  One, but not both interlocks, must terminate high voltage to the X-ray machine.
Any portion of an enclosure designed for routine entry that requires tools to gain access must be equipped with a single interlock at a minimum.

Enclosure walls that are not designed to be removed for routine access or maintenance and that require tools for removal, do not require interlocking.

All interlock systems must be fail-safe. 

Key Control

All X-ray machines must be equipped with a key control and/or a Prox key control that prevents the operation of the X-ray machine by untrained and unauthorized personnel.

X-ray machines equipped with an interlock bypass/override mode must be equipped with a separate key control and/or Prox key designation that controls activation of the bypass/override mode.

Open Beam Operation

Occasions may arise, such as performing primary beam alignments, that require an X-ray radiation worker to bypass/override the interlock system to gain entry into an X-ray enclosure while the X-ray tube is energized and the safety shutter is open.  Prior to performing open beam operations, the following conditions must be met:

• The interlock system must be designed with an interlock bypass/override system that is activated by key and/or the LBNL Prox key system,
• the system safety analysis document must fully describe the bypass/override functions of the interlock system and identify which interlocks are disabled when the bypass/override mode is activated,
• the X-ray enclosure must meet all the requirements of an enclosed beam enclosure when the bypass/override mode is disabled, and
• activation of the bypass/override mode must activate an audible alert that can be heard from within the enclosure and remains activated until the bypass/override mode is disabled.

In addition to the above requirements, the X-ray machine should:

• be equipped with a beacon or strobe within the enclosure, visible from all entrances to the enclosure, that is activated upon initiating open beam operation, and
• be fitted with a guard around the primary beam path that prevents accidental insertion of any body part into the primary beam.

21.7.8 Posting

Posting of warning signs and labels must be in accordance with EHS Procedure 709, Radiation Protection Posting, Labeling and Access Control.

All posting and labeling requirements will be specified in the applicable XA by the XSO.

21.7.9 Records

All X-ray machines are controlled items, requiring complete property management accountability records.

All X-ray machines must have a User's Logbook located near the machine, and a Maintenance Logbook.  As applicable, the User's Logbook must be used to record the following information:

• The user's name
• The experiment or procedure performed
• The number of exposures
• The techniques used
• The approximate time of use
• The date of use
• Any suspected abnormalities noted in machine operation
• The name of the responsible person to be notified of the above abnormality
• completion of interlock testing

All notifications of suspected machine abnormalities must be noted and addressed in the Maintenance Logbook.  All maintenance work on an energized X-ray machine is considered a use of that equipment and must be entered in the User's Logbook, with a reference to the location of a more detailed entry in the Maintenance Logbook.

The Maintenance Logbook is used to record the following information:

• The maintenance person's name and employer (if other than LBNL).
• The reason for maintenance (should refer to the User's Log entry of the noted abnormality).
• Specific problems noted during maintenance (need not be entered into the User's Log).
• Repairs performed (If modification is performed, give the date of written approval from the XSO).
• The time and date of maintenance operation.
• The signature of the maintenance person (indicates a certification that the machine is in normal working order, including all interlocking and fail-safe devices, and that circuitry and construction is in strict accordance with original manufacture plus approved modifications).

The User's Logbook and the Maintenance Logbook may be combined if deemed appropriate by the XSS. This combined logbook must be located near the machine, as would a User's Logbook, and must contain all information required for both logbooks.

21.7.10 Dosimetry

The XA defines the requirements for when whole-body OSL dosimeters and/or finger ring dosimeters for X-ray radiation workers are to be worn.  Specifically, finger ring dosimeters must be worn whenever engaged in interlock bypass/override operations.
Users of X-ray equipment who are required to be monitored for radiation exposure must properly wear appropriate personnel radiation dosimeters supplied by the RPG Dosimetry Office.

Because of the low penetrating nature of X-rays, whole body OSL dosimeters, when required, must be worn on the side of the body facing the X-ray equipment, at the level of the X-ray beam, and outside all clothing. The XSO or the Dosimetry Office should be consulted regarding proper use of personnel dosimeters.

Dosimeters are optional for X-ray users and for X-ray radiation workers when they are performing routine work with a fully enclosed and interlocked X-ray machine.

21.7.11 Radiation Safety Surveys

All X-ray machines must have a radiation safety survey performed by the XSO or designee upon installation but before regular use, at least once a year for machines in active use, and upon startup of machines that have been removed from service.  Additionally, each analytical X-ray machine must have an area monitoring device that continuously surveys the general environment (see area monitors below).

In addition, all X-ray machines must have a radiation safety survey performed:

• after a repair operation that could have caused a change in the condition of shielding or safety protection devices,
• after any repairs or maintenance that could affect the performance of an X-ray machine,
• following an amendment to an XA to increase operating voltage or current above the operating parameters of previous surveys, and
• upon request.

To supplement these major surveys, the XSS for analytical equipment may spot check the X-ray machine for radiation leakage.
All surveys and spot checks involve machine usage and therefore must be entered in the User's Log as such.

21.7.12 Routine Interlock Testing

The XSS is responsible for ensuring that X-ray machine safety systems are tested at the intervals specified in the system safety analysis.  This interval is usually six months and is specified in the XA.  The XSS may allow an authorized X-ray radiation worker listed in the XA to perform the interlock tests.  Interlock testing must be in accordance with the routine interlock Testing Protocol Checklist established as part of the system safety analysis.

The completion of interlock testing must be documented using the routine interlock Testing Protocol Checklist established in the system safety analysis.  The checklist must be signed and dated by the XSS or designated X-ray radiation worker and sent to the XSO.  A notation of findings and action taken must also be included.  A copy of the completed and signed checklist must be filed in the appropriate section of the X-ray Radiation Journal (XRJ) and the original sent to the XSO for filing in the RPG X-ray files.

21.7.13 Modifications

All modifications to X-ray generating systems must have the prior approval of the XSO.  Modifications affecting the safety or interlock system will require a new system safety analysis and amendment of the XA.

21.7.14 Use Control

Only authorized X-ray users are allowed to use X-ray machines.  To prevent unauthorized use, each X-ray machine must be controlled with a key control and/or the institutional access control system referred to as "Prox Key Access.”

21.7.15 Training

General Employee Radiological Training (GERT)

All personnel performing work within a Controlled Area for Radiation Protection (Controlled Area) must have successfully completed General Employee Radiological Training (GERT) (EH&S 405) and the GERT exam.  Training is valid for two years following the completion date.

X-ray users who use multiple X-ray machines may provide a copy of an X-ray user training exam completed within the previous two years to each XSS in lieu of retaking the user exam.  The exam must be kept on file in each applicable XRJ and the user expiration date shall be no more than two years from the exam completion date.

X-ray Users

All X-ray users must complete X-ray user training.  X-ray user training is provided by the XSS or a designated authorized X-ray radiation worker and is documented by completion of a written exam, which is provided by the XSO.  Completed exams must be filed in the Machine Specific Training section of the XRJ.  Training is valid for two years following the completion date.

X-ray Radiation Workers

Advance planning may be required to ensure training classes are available for all XSSs and X-ray radiation workers.  All XSSs and X-ray radiation workers must demonstrate satisfactory completion of EH&S 400 (401 for retraining) Radiation Protection – Fundamentals and EH&S 410 X-ray Radiation Protection.  Retraining, EH&S 401, must be completed within two years following completion of original training and every two years thereafter.  EH&S 401 is provided during the XA renewal process.  Completion of training must be tracked in the EH&S training database.

On-the-Job Training (OJT)

All X-ray users and X-ray radiation workers must receive OJT training from the appropriate XSS or designee for each X-ray machine they use.

At a minimum, OJT must include proper job-specific procedures for radiological safety, including

• safe work practices,
• limits and requirements of the XA,
• DOE and LBNL policy regarding X-ray machines,
• X-ray machine operating procedure, and
• emergency procedures, alarms, and access controls.

OJT training must be documented and signed by the individual who provided the training, as well as the individual who received the training.  Documentation of OJT must be filed in the appropriate section of the XRJ.  See Attachment A for an example OJT form.

Manufacturer and Other Service Personnel

Manufacturer service personnel and other non-LBNL service personnel are authorized to perform necessary work on a de-energized X-ray machine after successful completion of GERT and the GERT exam.  The XSS must:

• ensure service personnel complete GERT and the GERT exam,
• ensure that the X-ray machine is de-energized and controls are in place, such as removing keys from the X-ray machine control panel, to prevent the X-ray machine from being energized,
• ensure all maintenance is logged in the appropriate logbook, and
• ensure that the work performed will not disable or modify any safety system, such as interlocks, indicators, safety shutters, and enclosures.

Manufacturer service personnel and other non-LBNL service personnel who are required to perform work on an energized X-ray machine are authorized to perform the work on the X-ray machine without being added to the XA; however, the XSS or designee must:

• notify the XSO or backup XSO in writing at least 24-hours in advance,
• ensure service personnel complete GERT and the GERT exam,
• provide the XSO or backup XSO with written verification that the service personnel have completed X-ray radiation safety training equivalent to EH&S 400 and EH&S 410 and the training completion date,
• ensure all requirements of the XA are met and all precautions are followed, and
• ensure all maintenance is logged in the appropriate logbook.

Escort in Lieu of Training

Personnel performing work in accordance with this procedure may be exempted from the training requirements under the following conditions:

• The XSO or backup XSO has approved the use of an escort,
• the escorted individual is within constant direct line of sight and verbal communication with an escort,
• the escort is a fully trained and authorized X-ray radiation worker listed on the appropriate XA, and
• the use of an escort is documented on an escort form signed by the XSO or backup XSO, the escortee, and the escort.

21.7.16 Instrumentation

A radiation survey meter with appropriate energy response characteristics to serve as an X-ray detector should be used frequently to monitor for scattered radiation when working in an interlock bypass/override mode.  In addition, a fixed Geiger-Mueller or ionization-type area monitor is required for analytical X-ray machines. 

21.7.17 New Installations

New installations of X-ray machines must not be operated without prior approval of the XSO and performance of a system safety analysis.  An approved XA must also be in place.  Therefore, it is strongly advised that the XSO be consulted while the installation is still in the planning stage to review requirements such as shielding, interlocks, and safety devices.

21.7.18 X-ray Machine Classifications and Specific Supplemental Requirements

Analytical X-ray Equipment

Analytical X-ray machines are classified into two types:

• Enclosed-beam X-ray systems
• Open-beam X-ray systems

The definitions of these terms are contained in ANSI N43.2, subsection 6.2.1 - Classification.

The classification of enclosed-beam X-ray systems includes X-ray diffraction, X-ray fluorescence, and cabinet X-ray systems that meet the specifications in Section 21.7.7 of this chapter when operated in the fully interlocked mode.

The classification of open-beam X-ray systems includes all X-ray systems that do not meet the requirements in section 21.7.7 of this chapter and all enclosed beam X-ray systems operated in an interlock bypass/override mode.

In all cases, first consideration and effort must be given to making a system meet the requirements of an enclosed system. Approval to use an open-beam X-ray system is handled as a variance.

Portable X-ray Equipment

Portable X-ray equipment presents particular hazards due to its flexibility of use and therefore must be used more carefully. Extra caution and awareness of beam orientation and the location of personnel in the vicinity of the X-ray machine are essential.
The following specific provisions are required for portable X-ray generators:

• Fail-safe, obvious, and prominent visual indications that X-rays are being generated.
• Interlocks, if possible; however, the nature and use of portable X-ray machines often precludes interlocks.
• Periodic surveys for stray radiation.
• A key-controlled power switch on each unit.
• Adherence to all NCRP standards applicable to portable X-ray machines.

Additionally, reliable audio indication that X-rays are being generated should be provided.

Diagnostic X-ray Equipment

Medical diagnostic equipment safety is described in NCRP Reports 102 and 49. Since long exposures at high outputs are generally impossible with such units, interlocking is inappropriate; however, all such equipment must have a reliable, audible indicator that signals the production of X-rays.

The XA for this equipment must state whether the X-ray machine complies with state and federal regulations for use on humans.  Any X-ray machine to be used on humans must be found by the XSO to comply with these regulations before such use commences, unless specifically exempted by the Human Use Committee.

All diagnostic X-ray installations must, if possible, have a light outside the room that indicates when the X-ray control unit is energized and when X-rays are being produced. (A "rotor on" indication will suffice for the "X-ray On" indication.) These lights must be fail-safe or redundant. Furthermore, they must be positioned and labeled so that their presence and meaning are obvious.

21.7.19 Variances

If it is impossible or highly impractical to adhere to any safety standard, the XSS should request, in writing, a variance.  This request will be reviewed by the XSO and referred, with comment/recommendation, to the LBNL RSC or ESC, as appropriate, for consideration.

21.8 Additional Authorization Requirements

21.8.1 Accelerators

General

Radiological safety of accelerators is assured through appropriate authorization, either an RWA or an RWP as specified in other parts of this document.  Additionally, some accelerators may be required to comply with DOE O 420.2B Safety of Accelerator Facilities.  EH&S Procedure 703, Institutional Assurance of Accelerator Safety Order Compliance details the institutional process for determining which facilities require Order 420.2B compliance and for assuring on-going compliance.

Experimenters and operations personnel must consult with the RPG when planning new facilities or accelerator operations. Failure to consult RPG in the planning stage may result in delays.  Before any operation is begun at any LBNL accelerator, the RPG must conduct a review to determine if a radiological authorization (e.g., RWA, LDM or RWP) will be required and if the accelerator facility must comply with the DOE Order 420.2B or seek an exemption. If a radiological authorization is required, the RPG must conduct a detailed review of the proposed accelerator to determine the appropriate precautions, limitations, and ALARA practices necessary to ensure both good and safe work practices as defined in EH&S Procedure 705 or 707 as appropriate.

Induced Activity

Accelerator beams can produce induced radioactivity in components and equipment that are in close proximity to the beam. Materials removed from these areas must be characterized as to activity and radiation levels.

Items may not be removed from Accelerator Controlled Areas for unrestricted release until a release survey have been performed and the item tagged as released per EH&S Procedure 708. Only an RCT or specially trained and designated radiation workers may perform such surveys and tag items for release.

Occupancy of Beam Enclosures

LBNL policy requires radiation safety interlock systems at accelerators to protect personnel from accidental exposure to hazardous levels of radiation. Interlocks must be addressed in the RWA or RWP. Contact the RPG for further information about accelerator interlocks.
Occupancy of a beam enclosure while the beam is directed to that area is not normally allowed unless specifically permitted in either the RWA or RWP.  Entrances to such enclosures must be interlocked to the beam permissive-logic control system for safety. Overriding these safety mechanisms for purposes of convenience or expedience is strictly prohibited.  Experiments must be designed so that electronic or mechanical means are incorporated to monitor and to adjust the apparatus remotely if necessary.

Accelerator Radiation Protection Interlock Systems

Interlock systems protect personnel from accidental exposure to potentially high levels of radiation by excluding personnel from High-Radiation or Very-High-Radiation Areas. Beam interlock systems and warnings must be tested and serviced by the operating groups at least every twelve months, within the anniversary month. These requirements will be detailed in the applicable authorizing document.

21.8.2 Irradiators

General

An irradiator consists of a high-activity, sealed radioactive source housed in a shielded, interlocked chamber. Samples are inserted or brought into the chamber for exposure to radiation; then the chamber is closed and the source is moved remotely to the irradiation position. In general, the same safety requirements that apply to enclosed x-ray machines also apply to irradiators. In addition, an SSA will be required. The SSA incorporates requirements of the AHD by reference.

Responsibilities

The irradiator supervisor has the prime responsibility for compliance with safety requirements.

The responsibilities of the individual worker are as follows:

• Each worker must, upon the instruction of a qualified expert or responsible supervisor, follow the recommendations and instructions drawn up in the interest of radiation protection.
• Each worker must use the protective devices provided.
• Each worker must bring to the attention of those in charge any defect or deficiency in radiation protection devices and procedures.
  

Activity Hazard Document

All irradiators must have the most recent AHD readily accessible to authorized users. This AHD must contain at least the following:

• The name of the person responsible for the unit (system supervisor)
• A list of authorized users
• A list of authorized instructors
• A list of authorized maintenance personnel
• An emergency or problem call list
• Descriptions of safety features
• Specific operating procedures
• Copies of appropriate standards and policies, as provided by RPG
  

The AHDs must be prepared by the irradiator supervisor with consultation from RPG. The irradiator supervisor must review the AHD as frequently as changes in the program necessitate, but at least every 5 years. During this review, the irradiator supervisor must review the AHD and submit to the XSO any changes to be made or else indicate that there have been no changes. The AHD must also be reviewed when any item listed above changes, except for the list of authorized users, instructors, or maintenance personnel.

Irradiator System Safety Analysis Policy

The rules that apply to x-ray machines with respect to system safety analysis policy also apply to irradiators (see Section 21.7.4).

Sealed Source Authorization

All irradiators must have an SSA issued by RPG. The SSA must include the following information:

• The system supervisor's name, telephone number, mail stop, and division
• Any specific safety precautions
• References to the AHD, PUB-3000, and the RCM
• Emergency telephone numbers
• A list of authorized users

For more information on the RWA process, see Section 21.6, Radiological Work Authorization and Permit Programs.

Interlocks and Indicators

All irradiators must have failsafe interlocks and indicators as specified in applicable standards.

Posting

Posting of warning signs and labels must be in accordance with current standards and with the recommendations of the XSO. "High-Radiation Area" signs are required.

Records

The rules that apply to x-ray machines with respect to records also apply to irradiators (see Section 21.7.8).

Dosimetry

All users of irradiators must properly and continuously wear appropriate personal radiation dosimeters supplied by the Dosimetry Office. Dosimetry will be specified by the authorizing document.

Radiation Safety Surveys

All irradiators must have a radiation safety survey performed by the XSO or designee at least once a year for machines in active use and upon startup of machines that have been removed from service. Additionally, each irradiator must have an area monitoring device that continuously surveys the general environment.

In addition, all irradiators must have a radiation safety survey performed:

• Upon installation but before regular use
• After a repair operation that could have caused a change in the condition of shielding or safety protection devices
• Upon request

To supplement these major surveys, the irradiator supervisor or designee must spot check the irradiator at least every six months for radiation leakage.

All surveys and spot checks require use of the irradiator and therefore must be entered in the logbook.

Routine Safety Maintenance

The irradiator supervisor is responsible for ensuring that irradiator safety systems are checked at the intervals specified in the System Safety Analysis report. This interval is usually six months. A technician can be assigned by RPG to perform this service, which may be charged to the program. Safety system testing must be in accordance with the Routine Testing Protocol established as part of the System Safety Analysis.

The "Completion of Routine Maintenance" form and the Routine Testing Protocol checklist must be filled out and sent to the X-ray Safety Officer. A notation of findings and action taken must also be included.

Modifications

All modifications to any irradiator must be described in a System Safety Analysis and must have the prior approval of the XSO.

User Training

To become an authorized irradiator user, a person must complete installation-specific training is conducted by an instructor identified in the AHD.

To ensure continued awareness of procedures for machine operation, users must be recertified whenever the safety aspects of the AHD are changed, when they have not used the machine for more than one year, and at the discretion of the irradiator supervisor or XSO. Recertification must be completed at least every two years.

Instrumentation

A radiation dose-rate meter should be used to monitor radiation levels. A fixed monitor must be installed inside or at the entrance to the irradiation chamber connected to the interlock system.

Shielding

All irradiators must be shielded according to the direction of the XSO, with reference to prescribed standards and within the prescribed practice of ALARA.

New Installations

New irradiators may not be operated without prior approval of the XSO and performance of a System Safety Analysis. An AHD and an RWA must also be in place. Therefore, it is strongly advised that this officer be consulted while the installation is still in the planning stage so that he or she can review requirements such as shielding, interlocks, and failsafe devices.

21.9 Dosimetry

21.9.1 Personnel Radiation Exposure Limits and Controls

LBNL has established administrative control levels below federal dose limits (see Tables 21.1 and 21.2). These levels are monitored by personal dosimetry. Prior to exceeding any control level, written authorization is required from the appropriate level of management, as indicated in Table 21.2.

Table 21.1. Federal Exposure Limits

Table 21.2. LBNL Administrative Control Levels

Work activities that may result in annual dose equivalents above the administrative levels should be reviewed to ensure that adequate ALARA practices have been implemented.

The initial administrative control level was based on the historically low doses received at LBNL.

RPG must initiate an investigation of any abnormal or unanticipated personnel exposure exceeding 100 mrem or any uptake resulting in greater than 100 mrem committed effective dose equivalent (CEDE). The investigation should include a description of the circumstances and corrective actions to prevent recurrence.

If the Level 2 (or higher) administrative control level of this plan is exceeded without approval, the involved workers must be restricted from Radiological Areas. RPG must immediately initiate a review of the incurred exposure. The review should include an investigation of the circumstances and list corrective actions to prevent recurrence. The involved workers should not enter Radiological Areas until the incurred exposure is investigated and further exposure is properly approved.

21.9.2 Radiation Workers

In general, dosimetry will be required for all accelerator and x-ray-generating device users and for users of radioactive material who are likely to receive more than 100 millirem/year whole-body dose. Specified internal and external dosimetry requirements are listed in the controlling work safety document (AHD, RWA, RWP, SSA, or XA).

An investigation will be performed if there is any unplanned exposure exceeding any of the administrative control levels.

21.9.3 Workers Under 18 Years Old

No one under 18 years old should be employed in, or be allowed to enter, a Radiation Area or work with radioactive material where they can receive a total of more than 0.1 rem (1 mSv) per year from both internal and external doses. This age limit applies to all workers at the Laboratory, including employees, guests, students, and contractors. All requirements of the external and internal dosimetry programs and the RWA/RWP program also apply.

21.9.4 Declared Pregnant Workers

No declared pregnant worker may receive more than 0.5 rem (5 mSv) during the nine-month gestation period. The Laboratory has established a Declared Pregnant Worker Policy, which prescribes responsibilities for the worker and the Laboratory. Contact RPG for details.

21.9.5 Nonemployees and Visitors

The dose equivalent received by members of the public during direct onsite access shall not exceed 0.1 rem (1 mSv) per year based on the sum of both internal and external doses. In all cases, radiation exposures should be maintained as low as reasonably achievable (ALARA).

Contract personnel are the responsibility of their employers and are obligated by contract to comply with all pertinent DOE and LBNL safety and health regulations and requirements, including restrictions on personnel under 18 years of age.

21.9.6 Radiation Dose Reports

Personnel in the dosimetry program receive a report of their annual dose equivalent as required by the 10 CFR 835.

21.9.7 External Dosimetry Program

All radiation workers exposed to external ionizing radiation will be issued a dosimeter, as required by the RWA, RWP, SSA, XA, or AHD.

Thermoluminescent dosimeters (TLDs) and CR-39 are considered the primary dosimeters at LBNL. Any other dosimeter is supplemental.

RPG provides extremity dosimeters for personnel who have the potential to receive an extremity dose significantly higher than the whole-body dose. Personnel will be issued and must wear extremity dosimeters as required by their RWA or RWP. The dosimeters must be returned to the RPG Dosimetry Office for evaluation.

Pocket dosimeters (self-reading, gamma indication) must be worn as specified by the RWA, RWP, or AHD. Self-reading pocket and electronic dosimeters, called supplemental dosimeters, are worn simultaneously with the primary dosimeter.

All radiation workers must wear their dosimeters as required and are encouraged to wear their dosimeters at all times when at the Laboratory. The preferred location for wearing a dosimeter is the upper torso, where it will give the best estimate of the whole-body dose equivalent. The dosimeter must not be worn during nonoccupational activities, such as when undergoing medical or dental x-rays, nuclear medical procedures, radiation therapy, or air travel.

Laboratory personnel, both staff and guests, who might receive radiation exposures while working at other facilities will be issued dosimeters by the other facilities. The LBNL dosimeter must not be used to monitor occupational radiation exposures at other facilities.

Compliance with External Dosimetry Requirements

Personnel are responsible for following Laboratory procedures and for returning their dosimeters as prescribed. Supervisors are responsible for enforcing this procedure. Personnel who do not return their dosimeters during the prescribed period will receive a written reminder, as will their division safety coordinator.

Continued failure to return the dosimeters will result in notification of the appropriate division director, and the worker will be removed from any radiation work until an evaluation of the employee’s work practices has been completed.

Replacement costs of lost or damaged dosimeters and their holders will be charged to the worker’s program account.

21.9.8 Internal Dosimetry Program

The hazard analysis in the RWA/RWP process will determine the risk of internal intake of radioisotopes and whether internal dosimetry is required. The dose limits for internal radiation are based on the standards listed in the Internal Dosimetry Technical Basis. Laboratory policy requires that all Controlled Areas be kept as free as possible of airborne radioactivity and contamination.

RPG administers the program to monitor internal radiation dose equivalents to Laboratory employees. Line management supervisors are responsible for ensuring compliance with the program requirements.

The internal dosimetry program consists of in-vitro (body fluid) and in-vivo (whole-body counting) analyses. Workers who require internal dose monitoring must submit samples and have whole-body counts as scheduled.

Compliance with Internal Dosimetry Program Requirements

An employee who does not submit the requested in-vitro samples or complete the in-vivo analysis as required will receive a written reminder, as will the division safety coordinator. Continued noncompliance will result in notification of the appropriate division director, and the worker will be removed from any radiation work until an evaluation of the employee's work practices has been completed.

21.9.9 Area Monitoring Dosimeters

In order to minimize the number of areas requiring the issuance of personnel dosimeters and to demonstrate that the doses outside Controlled Areas for radiation protection are negligible, RPG is responsible for establishing and maintaining a comprehensive area dosimetry program.

Contact RPG if questions arise regarding placement or results of area dosimeters.

21.10 Workplace and Environmental Monitoring

21.10.1 Instruments

All radiation workers must have access to appropriate, calibrated radiation detection equipment. RPG provides guidance in the selection of instruments in addition to distribution, calibration, and maintenance. These instruments are delicate and expensive. Individuals who use them must be trained in instrument use and must be familiar with their limitations. It is the responsibility of the user to obtain adequate instrument training, to maintain the equipment in working order, and to obtain calibration when required. A tag on the instrument will indicate when calibration is due. (Calibrations are annual.) An RCT will facilitate calibration exchange.

Table 21.3. Types of Instruments

All of the following steps must be followed satisfactorily for the instrument to be used:

For details, see EHS Procedure 708, Release of Potentially Contaminated Material and Equipment.

21.10.2 Surveys

Radiation Surveys by Users

Radiation workers must conduct periodic radiation and contamination surveys to ensure that the safety controls are adequate. This involves surveying the work area, all work surfaces, the floors, the equipment, and the personnel. This should be done with portable equipment before, during, and after work that may change the radiological conditions of the work area. In areas where materials could be dispersed, causing contamination, swipe samples must be taken and analyzed on a suitable instrument. Positive results must be documented and reported to RPG.

Formal, documented surveys must be performed by radiation workers in accordance with provisions of the controlling SAD, AHD, RWA, RWP, XA, LAS, or GLA. The following information must be recorded for both swipe and meter surveys: name, date, time, instrument, LBNL serial number, calibration date (due), instrument background or control sample data, and results. Results should be linked to a map or diagram of the area. Survey results must be kept in the Laboratory Journal or equivalent that is available for inspection by RPG. Maps and survey forms are provided to each project by RPG.

RPG must be notified of radiation levels that could cause significant personnel exposure (>100 mrem/hr) or any unusual radiation fields. Corrective actions and rechecks must be documented. Additionally, notification is required if laboratory spaces cannot be decontaminated immediately or if contamination exceeds the limits in Table 21.4 below.

RPG Routine Surveys

Routine radiological contamination and radiation-level surveys will be made by RPG on a schedule that is commensurate with the radiological hazard and the potential for a change of conditions. Radiation workers will be notified of survey results and corrective actions, if required.

RPG Decommissioning Surveys

Radiation surveys will be performed to decommission areas to be released for unrestricted use, such as nonradioactive work, construction, or maintenance.

Release Surveys

Equipment or materials to be removed from areas where activation or contamination could occur must be surveyed and tagged by an RPG RCT. In some cases (for induced materials only), qualified radiation workers with special training can perform these surveys. In general, the areas requiring release survey of materials are the posted Radioactive Material Areas (RMAs), Radioactive Material Storage Areas (RSAs), Calvin Lab Controlled Areas, and Accelerator Controlled Areas. An updated list of these areas is published and distributed regularly. Note that Transportation will not move this equipment unless it has been tagged. Release monitoring procedures are specified in EH&S Procedure 708, Release of Potentially Contaminated Materials and Equipment.

Surface Contamination Surveys

Surface contamination levels must be surveyed by direct monitoring and swipe testing and must be below the limits given in Table 21.4.

Volume Contamination Surveys

Material that has the potential to have radioactive material that is dispersed throughout, rather than only on the surface, must be surveyed for volume contamination. Examples are objects than have been exposed to a neutron beam and contain activation products, or material that has become internally contaminated by introduction of radioactive material (soil, vacuum pump oil, lab material that has become cross-contaminated, etc.).

Typically, solid objects, such as beamline components or shielding blocks, will be surveyed externally with a NaI or HPGe detector to determine if radioactive material is present. Other materials, such as pump oil or soil, will be sampled and the sample analyzed at TSG for radioactivity. Survey and release criteria for volume contamination are specified in EHS Procedure 708.

Conditional Release

Materials and equipment determined to have volume activity or surface activity exceeding release limits may be released to other Controlled Areas. The material must be properly labeled, and appropriate procedures and authorizations must be in place at the new location. Equipment with removable contamination above release limits can only be transferred to an authorized Contamination Area. All contaminated equipment and materials must be monitored and transferred by EH&S, unless specific authorization is given by the Radiological Control Manager.

21.10.3 Airborne Sampling

Continuous-air sampling will be performed within areas where there is the potential for airborne radioactive contamination, based on an assessment of the operation via the RWA/RWP process. The controlling procedure is EHS Procedure 713, Laboratory Radiological Air Monitoring Program.

21.10.4 Environmental Sampling

Monitoring of ventilation emissions and offsite radiation levels is performed by the Environmental Protection Group. See PUB-3000, Chapter 11, Environmental Services Group, for more details.

21.11 Radiation Safety Requirements

21.11.1 Radiation Safety Training

10 CFR 835 requires all employees to receive radiation safety training prior to occupational exposure in a controlled area at a DOE facility and that such knowledge be verified by examination. Nonradiation workers who are at risk of radiation exposure must take GERT (see below). Radiation workers must complete more comprehensive training. If training is required, it must be repeated every two years. If qualified, an individual may satisfy the training requirement by challenge examination.

General Employee Radiation Safety Training

All new employees and participating guests intending to work more than one month must complete General Employee Radiation Training within the first month of employment. This is usually included as part of Introduction to Health & Safety at LBNL. Radiation-related information is included with EH&S information provided during the first day of employment. New employees complete a Job Hazard Questionnaire, which is reviewed by their supervisor and EH&S. Specific EH&S training is determined based on the answers to the Job Hazard Questionnaire.

Radiation Worker Training

An employee must successfully complete fundamentals training, hazard-specific training, and site-specific training to become qualified as a radiological worker. A radiological worker is an individual who has the potential to receive an exposure of over 100 mrem/yr. At LBNL this includes personnel who handle radioactive material, who frequent accelerator controlled areas, or who are assigned personnel dosimetry. Prior to completing training, an individual may work under direct supervision of a qualified radiation worker if they have received GERT. Different hazard-specific modules are required for laboratory, accelerator, and sealed source workers. Written exams are required for all training courses; practical exams are required for certain types of qualification. Requalification training is required every two years. Initial or requalification training may be completed by passing a challenge examination in lieu of classroom training, if properly qualified due to previous training and experience. Contact EH&S Training, for information regarding training requirements and test-out procedures. Employees completing radiation safety training at other DOE facilities may have fundamentals training waived if they provide proper documentation and satisfactorily complete LBNL site-specific training. Such documentation must include the employee's name, the date of training, the specific topics covered, and certification by an appropriate official. Wallet-sized "Certificate of Core Radiological Training" cards are issued for this purpose. Radiation safety training may be scheduled by calling EH&S Training.

Contractors

Contractors must meet the same radiation safety training criteria as employees. It is therefore imperative that coordination with RPG be made well in advance of target work dates so appropriate escorts or training may be arranged.

Additional radiation training policies for General Employees, Radiation Worker, and RCTs can be found in EHS Procedure 790. Contact RPG for your specific training requirements.

21.11.2 Controlled Areas, Posting, and Access

Certain areas at the Laboratory are designated as Controlled Areas in order to alert personnel to potential hazards from radiation or contamination. Controlled Areas are posted as such and may contain more-hazardous Radiological Areas within them. In some cases, the Radiological Area and the Controlled Area have the same boundary, and both postings appear together. Within Controlled Areas, Radiological Areas are identified by signs bearing the universal radiation symbol and the words "Radiation Area," "High-Radiation Area," "Very-High-Radiation Area," "Contamination Area," "High-Contamination Area," or "Airborne Radioactivity Area." Another area, called a Radiological Material Area (RMA) or Radiological Storage Area (RSA), which may be inside of or have the same boundary as a Controlled Area, is less hazardous than a Radiological Area, but the name indicates that radioactive materials are used or stored within it. These areas are defined in the glossary.

Access Requirements

Before entering any Controlled Area, workers must find out from the local area supervisors, the main control room at an accelerator, or EH&S the location and nature of potential radiation hazards in order to ensure proper radiation safety. Personnel must never attempt to enter a Radiological Area without permission and without being fully familiar with the operational safety rules for that particular facility. Radiological worker or GERT training is required before entry to a radiological area. These rules are included in the facility's AHD, which can be obtained from the facility's building manager or from RPG.

Entry-Control Program

An appropriate entry-control program must be established for any Radiological Area. The level of control must be consistent with the degree of hazard. Signs and barricades, control devices (e.g., locks) on entrances, conspicuous visual or audible alarms, or administrative procedures must be used as appropriate to control personnel entry into restricted areas. For High-Radiation Areas with dose rates greater than 1 rem (0.01 Sv) per hour at 30 cm from the source or from any surface that the radiation penetrates, the entry-control program must include at least one of the following:

The AHD, RWA, RWP, SSA, or XA will specify which controls are necessary in each case. (See Section 21.8.1, Accelerator Radiation Protection Interlock Systems.)

21.11.3 Radioactive Materials Safety

Workers wishing to begin using radioactive materials should contact RPG to receive guidance in applying for an authorization (see Section 21.6, Radiological Work Authorization and Permit Programs). Operations involving radioactive materials are restricted to those buildings (or areas within buildings) designated by RPG for such use. Such operations must be carried out only by qualified radiological workers and in accordance with the requirements of the governing authorization.

All chemical and mechanical operations on radioactive material must be designed to prevent the spread of radioactive contamination from the radiological work area and to reduce radiation exposure to ALARA levels. Each proposed use of enclosures or fume hoods must be reviewed in advance by RPG with respect to the amount of radioactive material to be used and the type of operation. Before any change in use of radioisotopes, RPG must be consulted so that the safety controls and procedures can be re-evaluated and the authorization can be amended and approved.

Radiological Assistance

Radiological assistance is normally available Monday through Friday, 8 a.m. to 5 p.m. Assistance outside these hours is available but must be arranged at least one week in advance. This is especially important during the Christmas-New Year shutdown. Normally, an RCT will be assigned to each area where radioactive materials are used. Generally, radiation safety services and information may be obtained through the RCT. When radiological assistance is needed after hours or on the weekend and there is no assigned RCT or the assigned RCT is unavailable, contact the after-hours support number, ext. 5251.

Safe Work Practices

• Workers who are assigned a personnel dosimeter must wear their dosimeters when in a Controlled Area.
• When working with radioactive material, employees must check for personnel contamination before, during, and after work. Mouth pipetting, eating, drinking, and smoking are prohibited in a Radiological Area, RMA, or RSA.
• Do not pour liquid radioactive waste into sanitary drains unless specifically authorized. If this is done by accident, notify RPG immediately.
• Air sampling requirements and locations will be specified in the RWA or RWP. Notify RPG if there is any malfunction of air sampling equipment.
• When leaving an RMA, employees must check for personal contamination by using a hand and foot counter or by thorough monitoring with the appropriate survey meter.
• All equipment and materials in an RMA must be monitored and tagged prior to removal.
• Enclosures and containers housing radioactive material must be labeled with a "Radioactive Materials" label showing the date and amount of radioactive material.
• Follow contamination-control practices when working with dispersible radioactive material:

• Reduce the radiation dose by using time, distance, shielding, and engineering controls effectively.
• When work is finished, dispose of and store materials and equipment properly.

Engineered Safety Enclosures

Safety enclosures are required for radiation use, based on the activity and dispersibility of the radioisotopes. These enclosures must meet specific engineering design requirements; notify EH&S whenever a new installation or modification of a safety enclosure is planned. The RWA or RWP hazard assessment will determine whether enclosures are required.

Fume Hoods

Fume hoods are designed to protect the operator by providing directional air flow. Since fume hoods are not typically filtered, they are not adequate for operations that might result in significant releases of radioisotopes to the atmosphere. For such operations, enclosures such as glove boxes must be used.

Wear a lab coat, disposable gloves, and other appropriate protective clothing at all times when working at a hood or wherever a chance of contamination exists.

If radioactive material is stored in a hood, it must be packaged safely and well shielded. A warning tag or sticker identifying the radioactive isotope, its level of activity, the date, etc., must be affixed in a prominent location outside the hood. RPG can advise on proper shielding of gamma emitters.

Never store flammables, explosives, and pyrophoric materials in hoods containing radioactive materials.

Acids, solvents, and heat sources can damage the inside surfaces of hoods, making any needed decontamination difficult. Always use protective coverings, such as sheet plastic, absorbent paper, or heat-resistant materials, as working surfaces.

The sliding front window of a fume hood protects against splashing chemicals and unexpected reactions and controls air velocity at the front of the hood. The recommended minimum air velocity of 100 fpm is achieved by matching the arrow on the side of the vertical sash with the arrow on the frame.

Periodically, hood ventilating systems must be shut down for maintenance or repair. Before any hood ventilating system is shut down, the occupants of the room must be notified.

Construction & Maintenance requires that the PI or supervisor render the hood as free as possible of radioactive and chemical contamination before hood repairs or modifications are begun. Ductwork must be checked by RPG personnel prior to any maintenance.

Glove Boxes

The basic glove box consists of an enclosure maintained by a manifold system at a negative pressure with respect to the room. Typical glove boxes used at the Laboratory are:

The radioisotope contents and the approximate level of radioactivity inside the glove box must be posted in a prominent location on the front of the box.

Glove boxes must always be adequately ventilated. Proper ventilation is indicated by a magnehelic, rotometer, or similar device. Ensure that the glove box has adequate flow prior to opening or performing work within a glove box. Exhaust-manifold control-box alarms occasionally go off because of power interruptions or malfunctions. Should this occur, immediately notify RPG. Never turn the control box off, and never disconnect a glove box from an exhaust manifold.

Box gloves and glove "O" rings must be checked visually and by instrument survey for holes and deterioration before each use of the box. If gloves or "O" rings need replacing, call RPG. Surgical gloves must be worn while using box gloves. Sharp objects inside the glove box must be placed in protective containers to prevent accidental puncture of gloves.

Box "pass-outs" and "pass-ins" must be done only by two properly trained personnel or with the assistance of RPG.

The amounts of flammable liquids or gases used in ordinary glove boxes must be small enough to prevent the buildup of explosive concentrations.

Never use a shielded glove box ("junior cave") until the radiation level inside the cave has been checked with the appropriate survey meter.

Check gloved hands for contamination when removing them from the box. Check hands and feet for contamination after working in a glove box and when leaving the work area.

Glove boxes are designed to resist earthquake damage and must be secured to prevent tipping.

Handling of Induced Radioactive Materials

Induced radioactive material, also commonly referred to as "activated" material, is material that has been made radioactive by bombardment with primary or secondary particles from accelerators or other sources.

Guidelines regarding induced radioactive material are as follows:

• Do not allow induced radioactive material that you are not using to accumulate. Dispose of induced material in accordance with EH&S Waste Management Group procedures for disposal of radioactive material.
• When an item is removed from a Controlled Area at an accelerator (such as an accelerator cave), it must be surveyed by an RCT or specifically trained and authorized radiation worker. If it is determined to be radioactive (see Section 21.10.11, Release of Material from Controlled Areas [not correct reference]), it must be labeled or tagged as such or placed in an RSA within the Controlled Area.
• A release (Green) tag will be placed on items that have been properly surveyed and determined to meet the release criteria in RPG Procedure 708. Do not remove items from a Controlled Area at an accelerator unless the item has a release tag.
• Items with removable contamination must be marked as such and wrapped. The outer containment must be surveyed and verified as free of removable radioactivity.
• Work to be performed on induced material must be covered by an RWA or RWP. Notify RPG well in advance of such work to prevent delays while a hazards analysis is conducted and a permit or authorization issued.
  

21.11.4 Radioactive Waste

More detailed information regarding radioactive waste is given in PUB-3000, Chapter 20, Hazardous Waste Disposal. Researchers and line management are responsible for compliance with waste requirements. All waste generators must complete Waste Generator Training. Radioactive waste must be collected in approved containers with properly filled-out inventory tags. Waste must be segregated by physical and chemical form according to EH&S instructions. Sharps must be placed in protective containers, and biohazardous waste must be deactivated. Animal and tissue waste must be kept frozen until pickup.

Generation and accumulation of radioactive waste, especially mixed waste (radioactive plus hazardous) must be minimized. Do not overfill waste containers, as this can cause area contamination.

It is especially important that radioactive waste be properly characterized. A waste accumulation log should be maintained so that the tag can be filled out accurately. Researchers and line management are responsible for compliance with waste requirements. Waste cannot be picked up unless appropriate conditions are met.

21.11.5 Procurement of Radioactive Material

Purchase of radioactive materials is completed via blanket order or purchase order.

The following steps should be taken when ordering radioactive materials:

Packages that are delivered to the recipient by the EH&S Transportation Office will include a sticker, placed on a copy of the packing list, indicating that the EH&S Transportation Office has surveyed the package for contamination. In addition, a Daily Use Log will accompany deliveries of unsealed materials. All radioactive material deliveries require an authorized radiation worker to sign for acceptance of the package. Notify the EH&S Transportation Office if you receive a shipment of radioactive material directly.

For sealed-source purchases, see Section 21.6.3, Sealed Source Authorization Procedures.

21.11.6 Transportation and Shipment of Radioactive Material

All incoming and outgoing shipments of radioactive materials must be handled by the EH&S Transportation Office unless special authorization is obtained.

Generally, there are six types of transfers, each of which require different procedures for approval. They involve transfers to:

An individual requesting to ship or transfer radioactive materials from the Laboratory must fill out a Hazardous Material Request for Shipment form, available from the EH&S Transportation Office. At least 2 days' prior notice is required for domestic shipments, and 5 days' prior notice for international shipments. After receiving approval for the shipment, the material must be given to the EH&S Transportation Office to prepare the packaging and paperwork for U.S. Department of Transportation (DOT) compliance.

Unauthorized off-site transfers or shipments of radioactive material may result in potential financial liability for the laboratory, and public hazard problems. In addition, the consignee must posses a license to receive the material. Moreover, these materials are the property of the U.S. government and must be accounted for in accordance with established procedures.

On-site transfers of radioactive materials must be coordinated with RPG and the EH&S Transportation Office. See RPG Procedure 750 and the appropriate work authorization(s) for requirements regarding onsite transportation of radioactive materials.

21.11.7 Decontamination of Radioactive Equipment

Articles that are of sufficient value to make recycling economical may be decontaminated with assistance from EH&S. The RPG group will determine whether decontamination is feasible. Proper packaging and identification of these items must be performed with assistance from an RPG RCT. Glove boxes, hoods, and other enclosed work areas may be decontaminated in place with assistance from an RPG RCT. Contaminated clothing and other personal items must be decontaminated before they can be removed from the Laboratory. In general, the RPG group should be contacted before cleaning any equipment that is contaminated greater than the Table 21.4 levels.

21.12 Procedures for Emergencies Involving Radioactive Material

21.12.1 Responsibilities

All Employees

• Be familiar with your emergency plan
• Know your evacuation route
• To evacuate, use stairs, not the elevator
• Note the locations of emergency showers and eyewashes, fire pull boxes, and fire extinguishers
  

Supervisors

• Emergency shutdown procedures for hazardous operations must be posted in a safe and conspicuous location
• Post and maintain a current emergency call list
• Conduct pre-work reviews, including emergency responses
• Address emergency issues in planning and design processes
  

For further details see PUB-3000, Chapter 9, Emergency Management.

21.12.2 Spill Classification

Radioactive spills are divided into two categories, minor spills and major spills.

A minor spill is a spill that is contained within the boundary of an RMA or RSA, radioactive material has not contaminated the floor, and in which no radioactive material has made contact with skin or personal clothing. All three conditions must be met. Authorized radiation workers may initiate cleanup prior to contacting the RPG for assistance.

In the case of a major spill, contact the RPG or x7911 immediately. Any spill of radiological material that has made contact with the floor, personal clothing or skin or that spreads outside the RMA or RSA is a major spill.

21.12.3 Handling a Radiological Emergency

When an emergency arises, use the SWIMS concept. The SWIMS concept will help you remember the proper actions to take during an emergency. SWIMS stands for:

S Stop and Think. Stop Working. Stop the Spill.

Assess the situation:

• How big is the spill?
• Is it contained within the boundary of an RMA or RSA?
• Has it made contact with skin, personal clothing, or the floor?
• Does it have the potential to become airborne?
  

W Warn others.

• If there is a medical emergency or danger to life, health, or the environment, call 7911 or 9-911.
• If there is no medical emergency or danger to life, health, or the environment, call the assigned RCT or RCT backup. After hours call 7911.
• Alert all people in the laboratory to the emergency.
  

I Isolate the area.

• Restrict access.
• Determine the extent of the spill.
• Tape or rope off the area. Keep doors closed.
  

M Monitor yourself carefully and completely.

• Change gloves.
• Monitor hands, sleeves, front of body and shoes (top and bottom).
• Remove contaminated clothing and place in plastic bag.
• If contaminated, try to determine the radioactivity level (CPM) and the total surface area covered by the contamination (e.g., 20 cm2). Wash skin with mild soap and tepid water.
• Check yourself for any chemical contamination or reactions (wet clothing, skin, or respiratory irritation).
  

S Stay in or near the area until help arrives.

• Minimize your movements.
• Have a person knowledgeable of the incident assist Emergency Personnel.
• Notify your supervisor.
  

21.12.4 Reporting an Emergency

• Contact the RPG group immediately or x7911. If the incident involves personal injury, fire, or any other nonradiological emergency, call x7911 immediately.
• Stay calm; speak clearly.
• Give your name and the location of the emergency.
• State the nature of the emergency (radiation, chemical, personal injury).
• Describe the severity.
• Relay other potential hazards (exposures, flammables, high voltage).
• Stay in the area until help arrives, if possible.
  

21.12.5 Suspected Radioactive Contamination to Personnel or an Area

• Contact the RPG group immediately. After hours, report the event via 5251 (EH&S) or 6015 (Fire Department non-emergency number).
• Evacuate personnel to a safe area. Isolate and deny entry to contaminated area.
• Detain all evacuees to avoid spreading contamination and for evaluation by EH&S.
• Do not attempt decontamination of the equipment or work area.
• Preserve the scene.
• For personnel contamination, also see Section 21.12.6.
  

21.12.6 Injured Personnel and Suspected Radioactive Contamination to Personnel or to an Area

• Immediately call 7911. Report injury and possible radioactive contamination.
• Apply first aid. First aid can be rendered to the level to which the aid giver is trained.
• Avoid moving the victim if possible. Weigh the risk of moving the victim against the risk of potential exposure.

21.12.7 Personnel Contamination

• Contact the RPG group immediately. After hours or if there are injured personnel, call 7911.
• Do not try to decontaminate a wound.
• Remove contaminated clothing in a manner that prevents further spread of contamination.
• After determining the activity level (CPM) and the extent of the area covered by the contamination (e.g., 20 cm²), gently wash the skin with mild soap and tepid water, using absorbent paper to collect the washing liquid.
• Do not use solvents or abrasive cleaners.
• Do not redden or abrade the skin.
• Try to prevent the release of radioactivity into the sanitary sewer. Tip: Place a small empty garbage can, using an empty bag as a liner, into a sink and collect all washing fluids in the bag. This will prevent the release of radioactive material into the sanitary sewer.
  

21.12.8 Investigation

All radiological emergency incidents will be investigated by RPG, and a report relating to causes, prevention, actions taken, results of cleanup and monitoring, lessons learned, etc., will be prepared. Incidents that must be reported pursuant to DOE Order 232.1A, Occurrence Reporting, include overexposures, personal clothing or skin contamination, contamination outside a Controlled Area, and violations of procedures. These incidents have reporting deadlines and must be categorized immediately. More serious occurrences will have a report prepared by an RSC investigation committee. The committee will consist of line management and a qualified representative of RPG.

21.13 Glossary

Activation is the process of producing a radioactive material by bombardment with neutrons, protons, or other nuclear particles.

An administrative control level is a numerical dose constraint established at a level below the regulatory limits in order to administratively control, and help reduce, individual and collective doses.

An airborne radioactivity area is any area accessible to individuals, where the concentration of airborne radioactivity, above natural background, exceeds or is likely to exceed the derived air concentration (DAC) values listed in Appendix A or Appendix C of 10 CFR 835; or where an individual present in the area without respiratory protection could receive an intake exceeding 12 DAC-hours in a week.

The annual limit on intake (ALI) is the derived limit for the amount of radioactive material taken into the body of an adult worker by inhalation or ingestion in a year. The ALI is the smaller value of intake of a given radionuclide in a year by the reference man (ICRP Publication 23) that would result in a committed effective dose equivalent of 5 rem (0.05 sievert), or a committed dose equivalent of 50 rem (0.5 sievert) to any individual organ or tissue.

As low as reasonably achievable (ALARA) describes an approach to radiological management and control that aims to keep exposures (individual and collective) to the workforce and to the general public at levels as low as is reasonable, taking into account social, technical, economic, practical, and public policy considerations. As used in this manual, ALARA is not a dose limit but a process that has the objective of attaining doses as far below the applicable controlling limits as is reasonably achievable.

Background radiation is radiation from cosmic sources; naturally occurring radioactive materials, including radon (except as a decay product of source or special nuclear materials); and global fallout as it exists in the environment from the testing of nuclear explosive devices. Background radiation does not include radiation from source, byproduct, or special nuclear materials.

The becquerel (Bq) is the International System (SI) unit for activity of radioactive material. One becquerel is that quantity of radioactive material in which one atom is transformed per second or undergoes one disintegration per second.

A bioassay is an internal dosimetry test used to determine the kinds, quantities, concentrations, and in some cases the locations of radioactive materials within or excreted from the human body. This process includes whole-body and organ counting, as well as urine, fecal, and other specimen analysis.

Calibration is the process of adjusting or determining one of the following:

A containment device is a barrier, such as a glove box or fume hood, for inhibiting the release of radioactive material from a specific location.

A Contamination Area is an area where ambient contamination levels are more than those specified in 10 CFR 835, Appendix D.

In a contamination survey, swipes or direct instrument surveys are used to identify and quantify radioactive material on personnel, on equipment, or in areas.

A Controlled Area is any area to which access is managed in order to protect individuals from exposure to radiation or radioactive materials. Individuals who enter Controlled Areas, without entering Radiological Areas, are not expected to receive a total effective dose equivalent of more than 0.1 rem (0.001 sievert) in a year.

Controlled Items, as designated by the Laboratory’s Property Management Office, are items that shall be kept under inventory control, regardless of value.

A declared pregnant worker is a woman who has voluntarily informed her employer in writing of her pregnancy and the estimated date of conception.

Decontamination is the process of removing radioactive contamination and materials from personnel, equipment, or areas.

A deep dose is the dose equivalent from external radiation determined at a tissue depth of 1 cm.

The derived air concentration (DAC) is the airborne concentration equal to the ALI divided by the volume of air breathed by an average worker for a working year of 2000 hours (assuming a breathing volume of 2,400 m³).

A dose is an amount of energy deposited in body tissue because of radiation exposure. Various technical terms, such as dose equivalent, effective dose equivalent, and collective dose, are used to evaluate the amount of radiation an exposed worker receives. These terms are used to describe the differing interactions of radiation with tissue as well as to assist in the management of personnel exposure to radiation.

Dose assessment is the process of determining the radiological dose and the uncertainty included in the dose estimate through the use of exposure scenarios, bioassay results, monitoring data, source term information, and pathway analysis.

Engineering controls are components and systems used to reduce airborne radioactivity and the spread of contamination by using piping, containments, ventilation, filtration, or shielding.

An exclusion area is an area defined by a qualified expert as one that all personnel should be restricted from entering during operation of an accelerator.

Extremities include hands, feet, arms below the elbow, and legs below the knee.

Being failsafe means having the property that any single failure causes a sequence of events that always results in a safe situation.

A failsafe design is one in which all single-component failures of indicators or safety systems (that can reasonably be anticipated) cause the equipment to fail so as to maintain personnel radiation safety. For example, if a light indicating “X-ray on” fails, the production of x-rays is prevented; similarly, if a shutter-status indicator fails, the shutter closes.

Fixed contamination is radioactive material above the appropriate limits specified in 10 CFR 835, Appendix D, that cannot be readily removed from surfaces by nondestructive means, such as casual contact, wiping, brushing, or washing.

Frisking is the process of monitoring personnel for contamination. Frisking can be performed with hand-held survey instruments or automated monitoring devices.

General Employees are all DOE or LBNL employees, subcontractors, and participating guests.

The Gray (Gy) is the SI unit of absorbed dose. One gray is equal to an absorbed dose of 1 joule per kilogram (100 rads).

A High-Contamination Area is an area where ambient contamination levels are higher than 100 times those specified in 10 CFR 835, Appendix D.

A high-efficiency particulate air (HEPA) filter is a extended, pleated medium dry–type filter with (1) a rigid casing enclosing the full depth of the pleats, (2) a minimum particle removal efficiency of 99.97% for thermally generated monodisperse DOP smoke particles with a diameter of 0.3 mm, and (3) a maximum pressure drop of 1.0 inch w.g. when clean and operated at its rated airflow capacity.

A High-Radiation Area is any area, accessible to individuals, in which radiation levels could result in an individual receiving a deep dose equivalent in excess of 0.1 rem (0.001 Sv) in one hour 30 cm from the radiation source or from any surface that the radiation penetrates.

An irradiator is a sealed radioactive material that has the potential to create a radiation level exceeding 500 rad (5 grays) in 1 hour at a distance of 1 meter.

Mixed waste is waste containing both radioactive and hazardous components as defined by the Atomic Energy Act and the Resources Conservation and Recovery Act, respectively.

Low Activity Source (LAS) Authorizations allow use or transfer of radioactive materials with very low activity, provided that a project does not possess more than ten such quantities. Compliance with regulations and other provisions of EH&S programs is required.

Occupational dose is the dose received by a person during employment in which the person’s assigned duties involve exposure to radiation and to radioactive material. An occupational dose does not include doses received from background radiation, from medical procedures, from voluntary participation in medical research programs, or as a member of the public.

Personal protective equipment is equipment such as respirators, face shields, and safety glasses that is used to protect workers from excessive exposure to radioactive or hazardous materials.

Personnel dosimeters are devices such as film badges and thermoluminescent dosimeters (TLDs) designed to be worn by a single person for the assessment of his or her dose equivalent.

Personnel monitoring describes systematic and periodic estimates of radiation doses received by personnel during working hours. The term is also used for the monitoring of personnel, their excretions, their skin, or any part of their clothing to determine the amount of radioactivity present.

The exposure of an embryo or fetus to radiation is known as prenatal radiation exposure.

The operation of any accelerator will result in radiation called prompt radiation, as distinguished from induced radioactivity. Prompt radiation stops as soon as the accelerator is turned off.

A qualified expert is a person having the knowledge and training to measure ionizing radiation, to evaluate safety techniques, and to provide advice on radiation protection needs as determined by LBNL Management.

The rad is a unit of absorbed dose. One rad is equal to an absorbed dose of 100 ergs per gram or 0.01 joules per kilogram (0.01 gray).

A Radiation Area is any area, accessible to individuals, in which radiation levels could result in an individual receiving a deep dose equivalent in excess of 0.005 rem (0.05 mSv) in one hour 30 cm from the radiation source or from any surface that the radiation penetrates.

The Radiation Safety Committee (RSC) is responsible for advising LBNL Management on all matters related to occupational and environmental radiation safety. The RSC provides oversight to the Radiation Protection Program (RPP), including the ALARA program.

A Radiological Work Authorization (RWA) is an authorization for use of radioactive materials in long-term projects having stable radiological conditions. Precautions, limits of use, and requirements are specified.

A Radiological Work Permit (RWP) is a permit that identifies radiological conditions, establishes worker protection and monitoring requirements, and contains specific approvals for specific radiological work activities. The Radiological Work Permit serves as an administrative process for planning and controlling radiological work and informing the worker of the radiological conditions. A permit for construction or demolition work in a Radiological Material Area is one example.

A Radiological Material Area (RMA) is an area or structure where radioactive material is used, handled, or stored.

A Radiological Storage Area (RSA) is a structure or designated area in which radioactive material is stored.

A radioactive material is any material, equipment, or system component determined to be contaminated or suspected of being contaminated. Radioactive material also includes activated material, sealed and unsealed sources, and material that emits radiation.

Radiography is the nondestructive examination of the structure of materials by using a radioactive source, x-ray machine or accelerator.

A radiological posting is a sign or label that indicates the presence or potential presence of radiation or radioactive materials.

Radiological work is any work that requires the handling of radioactive material or requires access to Radiation Areas, High-Radiation Areas, Contamination Areas, High-Contamination Areas, or Airborne Radioactivity Areas.

A radiological worker is a worker whose job assignment requires work on, with, or in the proximity of radiation-producing machines or radioactive materials AND has the potential of being exposed to more than 0.1 rem (1 mSv) per year, which is the sum of the dose equivalent from external irradiation and the committed effective dose equivalent from internal irradiation. A radiological worker may also be referred to as a “radiation worker” or a “rad worker.”

Release to Uncontrolled Areas is the release of material from administrative control after confirming that the residual radioactive material meets the guidelines in DOE Order 5400.5 and 10 CFR 835, Appendix D.

The rem is a unit of dose equivalent. The dose equivalent in rem is numerically equal to the absorbed dose in rad multiplied by a quality factor, a distribution factor, and any other necessary modifying factor (1 rem = 0.01 sievert).

Removable contamination is radioactive material that can be removed from surfaces by nondestructive means, such as casual contact, wiping, brushing, or washing.

Radioactive material that is contained in a sealed capsule, sealed between layers of nonradioactive material, or firmly fixed to a nonradioactive surface by electroplating or other means is called a sealed source. The confining barrier prevents dispersion of the radioactive material under normal, and most accidental, conditions related to use of the source.

A Sealed Source Authorization (SSA) authorizes possession and use of sealed sources. Precautions, limits of use, and other requirement are specified.

The sievert (Sv) is the SI unit of any of the quantities expressed as a dose equivalent. The dose equivalent in sievert is equal to the absorbed dose in grays multiplied by the quality factor (1 Sv = 100 rem).

Techniques are instrument use parameters employed during an X-ray exposure, e.g., kV, mA, mAs, sec, filter, distance, field size, etc. (Not all parameters are, of course, applicable to all types of X-ray machines.)

An Uncontrolled Area is any area where access is not restricted and the effective dose equivalent received by any member of the public resulting from exposure during direct on-site access does not exceed a limiting value of 0.001 sievert (0.1 rem) in any year.

An unusual occurrence is a nonemergency occurrence that has significant impact or potential for impact on safety, environment, health, security, or operations. Examples of the types of occurrences that are to be categorized as unusual occurrences are listed in DOE Manual 232.1A.

A Very-High-Radiation Area is any area, accessible to individuals, in which radiation levels could result in an individual receiving an absorbed dose in excess of 500 rads (5 grays) in one hour, 1 meter from a radiation source or from any surface that the radiation penetrates.

An x-ray accessory apparatus is any portion of an x-ray installation that is external to the radiation source housing and into which an x-ray beam is directed for making x-ray measurements or for other uses.

The x-ray tube and that portion of an x-ray system that provides the accelerating voltage and current is the x-ray generator.

An X-Ray System Supervisor is a person having administrative control over an x-ray machine and is so designated in the X-ray Machine Safety Document for that machine.

21.14 Standards

21.15 Related PUB-3000 Chapters

21.16 References

21.17 Appendices

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