Radiation Safety Policy

Policy number17-05.6
Responsible officeResearch
Enforcement officialRadiation Safety Officer
ClassificationBoard of Trustees-delegated Policy
Category17. Research and Intellectual Property

Statement of policy

This policy establishes the duties and responsibilities for the Radiation Safety Program to ensure compliance with the United States Code of Federal Regulations (CFR) and Public Acts of the State of Michigan. These laws and acts require that the University establish and enforce a written policy to govern activities using radioactive materials and/or radiation producing devices to ensure the safety of the public, employees, and students.

Summary of contents/major changes

This policy provides a clear definition of the titles and organizations with authorities and responsibilities to ensure compliance with the rules and regulations. The legal and local consequences of non-compliance are provided as well the sanctions that could be administered to individuals failing to comply with the rules, regulations, procedures, guidelines, and standard practices. It further provides a list of sub-programs and procedures which shall be maintained to ensure the policy meets its intent.  August 15, 2017, version is being moved into required policy template.  No substantive changes.

Purpose of Policy

  1. Federal and State of Michigan rules and regulations require Western Michigan University (WMU) to assure that exposure to radiation is ALARA (As Low As Reasonably Achievable). The Radiation Safety Policy sets forth the means by which the University complies with applicable rules and regulations. The Radiation Safety Policy further stipulates the duties and responsibilities for the development, implementation, and oversight to ensure the safe use of radiation.

  2. Stakeholders Most Impacted by the Policy

    This policy applies to all personnel in facilities or on property owned or controlled by WMU and utilizing radioactive materials or radiation producing devices.

  3. Key Definitions
    • 3.1 NUREG: The abbreviation for the US Nuclear Regulatory Commission’s regulations. These documents come either separately or within volumes. They provide clarifying information as it pertains to the Code of Federal Regulations.
    • 3.2 License: The official authorization given by the United States Nuclear Regulatory Commission (NRC) to possess and use radioactive material and includes the stipulations by which the University must abide.
    • 3.3. Radiation Safety Officer (RSO): The individual hired by the University and given the authority to develop, maintain, and enforce the WMU Radiation Safety Program.
  4. Full Policy Details
    • 4.1. Duties of those responsible for the Radiation Safety Program
      • 4.1.1. Executive Management Team is comprised of the President, Vice President for Research, and the Associate Vice President for Research.
      • 4.1.2. Executive Manager (Associate Vice President for Research)
        • 4.1.2.1. The Executive Manager administers the Radiation Safety Policy and has been given the authority and means to ensure compliance.
        • 4.1.2.2. Make prompt decisions without having to consult with higher management, particularly in case of an emergency concerning radiation.
        • 4.1.2.3 Take actions necessary to ensure all radiation safety practices comply with the rules and regulations governing the use of radioactive material or radiation producing machines.
        • 4.1.2.4. Participate in the Quality Control Program and support the Radiation Safety Officer (RSO).
      • 4.1.3. Radiation Safety Officer (RSO)

        Responsibility for these duties may not be transferred to other individuals. Tasks and duties may be assigned or delegated; however, the responsibility for these tasks and duties is the RSO’s.

        • 4.1.3.1. The RSO reports to the Executive Manager and is responsible for the development, maintenance, and enforcement of the WMU Radiation Safety Program.
        • 4.1.3.2. The RSO shall have access to all buildings and research where radioactive material or radiation producing devices are used or stored.
        • 4.1.3.3. The RSO has the authority to alter, modify, suspend, or terminate any use of licensed or registered material that in his judgement is a threat to the health and safety of the general public, WMU Authorized Users (AUs), Radiation Workers (RWs), or the environment due to violations of any rules, regulations, or conditions of our Nuclear Regulatory Commission Material Licenses or State of Michigan registrations governing our use of materials or devises.
        • 4.1.3.4. The RSO oversees the Radiation Safety Program with duties and responsibilities that shall ensure compliance with the rules, regulations, and procedures governing radiation and its use.
        • 4.1.3.5. Serve as a liaison between WMU and all regulatory agencies on matters pertaining to radiation.
        • 4.1.3.6. Direct the sub-programs and procedures that comprise the Radiation Safety Program.
        • 4.1.3.7. Review and approve proposed uses, users, and rooms.
        • 4.1.3.8. Maintain all documentation required by the Radiation Safety Program.
        • 4.1.3.9. Direct and/or conduct the phases of corrective actions to prevent recurrence of incidents involving radiation or radioactive material.
      • 4.1.4. Authorized Users are approved by the RSO after verification of the individuals’ training and experience.
        • 4.1.4.1 Responsible for complying with all rules, regulations, procedures, and policies that govern the use of radioactive material and radiation producing machines.
        • 4.1.4.2. Participate in the Quality Control Program.
        • 4.1.4.3. Notify the RSO of any violations or deviations from the rules, regulations, procedures, ALARA practices, or unusual events involving the use of radioactive material or exposure.
        • 4.1.4.4. Assist the RSO in investigating, determining the cause of, developing corrective action, and implementing actions to prevent recurrence of incidents involving radiation.
        • 4.1.4.5. Practice and promote ALARA (As Low As Reasonably Achievable) principles and standards.
        • 4.1.4.6. Ensure that individuals working under their direct supervision are properly supervised and trained to maintain ALARA and compliance with all rules, regulations, procedures, and policies that govern the use of radioactive material and radiation producing machines.
      • 4.1.5. Radiation Workers are the individual users and the direct handlers/users of radioactive material and radiation producing devices.
        • 4.1.5.1. Responsible for complying with the radiation safety rules and regulations.
        • 4.1.5.2. Notify their AU and/or the RSO of any violations or deviations from the rules, regulations, procedures, ALARA practices, or unusual events involving the use of radioactive material or exposure.
        • 4.1.5.3. Practice and promote ALARA (As Low As Reasonably Achievable) principles and standards.
      • 4.1.6. Division of Environmental, Health, and Safety (EHS) will assist the RSO in fulfilling Radiation Safety Program requirements as requested by the RSO or Executive Manager.
    • 4.2 Organizational Structurea hierarchy that shows president overseeing vice president for research overseeing Executive Manager  (Associate Vice President for Research) overeeing Radiation Safety Officer overseeing Authorized Users, Radiation Workers, Radiation Machine and Radiation Workers
  5. Accountability and Consequences of non-compliance
    • 5.1. Legal Consequences:
      • 5.1.1. WMU is the licensee for a Nuclear Regulatory Commission (NRC) Materials License and any one individual or action that jeopardizes the ability to obtain and keep that license endangers the ability to conduct research using radioactive material. If, for any reason, the license is suspended or terminated no one will be able to use radioactive materials of any kind. Therefore, every individual is responsible not only to maintain compliance with all rules, regulations, procedures, and policies that govern the use of radioactive material, but also to promote a safe working environment through his/her radiation and contamination control practices.
      • 5.1.2. Failure of an individual to conduct his/her research within the rules, regulations, procedures, and policies made in the license application or registration, subsequent amendments, or correspondence can result in enforcement action, against WMU, the Executive Management, the RSO, and/or the individual:
        • 5.1.2.1. Notice of violation which would result in increased NRC oversight.
        • 5.1.2.2. Imposition of a civil penalty against the University, RSO, or the individual.
        • 5.1.2.3. Suspend, modify, or revoke the University’s material license as specified in the General Statement of Policy and Procedure for NRC Enforcement Actions.
        • 5.1.2.4. Suspend or prohibit the individual from involvement in licensed activities for a specified time while at the University or any other entity.
      • 5.1.3 All persons involved in the use of radioactive material may be subjected to inspections by the NRC, the State of Michigan, WMU Executive Management, and the RSO or designee to assure compliance with all relevant rules and regulations.
    • 5.2. Local Consequences
      • 5.2.1. Because of the serious consequences to the general public and radiation, the RSO shall take prompt and decisive action when dealing with individuals who do not achieve the meticulous attention to detail and high standard of compliance expected of them.
      • 5.2.2. The RSO will document violations and deviations of the rules, regulations, procedures, and policies that govern the use of radioactive material.
      • 5.2.3. The RSO shall determine and document the sanctions, if any, necessary to prevent recurrence.
      • 5.2.4. Sanctions that may be given by the RSO in the order of severity, least to most:
        • 5.2.4.1. Meeting with the RSO, the Authorized User (AU), and the individual; may also include the Executive Manager.
        • 5.2.4.2. Require retraining of the individual.
        • 5.2.4.3. Restrict use of radioactive materials.
        • 5.2.4.4. Terminate the privilege to use radioactive material.
  6. Review Process
    • 6.1. This policy shall be reviewed no less than every three years.
    • 6.2. Reasons to review/revise earlier include changes in legal, technological, or program requirements.
  7. Related Procedures and Guidelines that comprise the Radiation Safety Program
    • 7.1. Training Program consists of three different courses; Basic Radiation Safety, Authorized User, and Refresher training.
    • 7.2. Radiological Controls Program consists of procedures and practices used to maintain exposure to the general public and WMU AUs/RWs ALARA.
    • 7.3. Quality Control Program consists of the procedures and practices used to ensure that the procedures and practices used at WMU are of the highest standards.
    • 7.4. Source Inventory and Control Program consists of procedures and practices used to ensure compliance with the quantity and type of material specified by the University’s material licenses.
    • 7.5. Instrumentation and Dosimetry Program consists of the procedures and practices used to obtain accurate exposure measurements.
    • 7.6. Radioactive Waste Program consists of the procedures used to minimize, control, store, and dispose of radioactive waste generated at WMU.
    • 7.7. Transportation of Radioactive Material/Waste Program consists of the procedures used to ensure compliance with the rules and regulations governing the conveyance of licensed material over public roadways.
    • 7.8. Administrative Controls Program consists of the procedures that specify the requirements for: record and documentation management; the information and criteria for becoming an Authorized User; and information needed to get approval for additional uses and facilities.
    • 7.9. Emergency Plan consists of procedures used to minimize the potential exposure of or to the general public and radiation workers by providing immediate responsive actions to emergencies involving an unplanned release of radioactive material or unplanned exposure rates.

References

  • NUREG 1556 Vol. 7, Program-Specific Guidance About Academic, Research and Development, and Other Licenses of Limited Scope, February 2018.
  • NUREG 1556 Vol. 11, Program-Specific Guidance About Licenses of Broad Scope, February 2017.
  • NRC Material License No. 21-03336-09 issued to Western Michigan University on July 07, 2017.
  • NRC Material License No. 21-03336-10 issued to Western Michigan University on May, 24, 2012.
  • 10CFR19, Notices, Instructions and Reports To Workers: Inspection And Investigations
  • 10CFR20, Standards for Protection Against Radiation
  • 10CFR30, Rules of General Applicability to Domestic Licensing Of Byproduct Material
  • 10CFR33, Specific Domestic Licenses of Broad Scope For Byproduct Material
  • 10CFR37, Physical Protection of Category 1 and Category 2 Quantities Of Radioactive Material
  • 10CFR40, Domestic Licensing of Source Material
  • 10CFR61, Licensing Requirements for Land Disposal of Radioactive Waste
  • 10CFR71, Packaging and Transportation of Radioactive Material
  • 49CFR172, Hazardous Materials Table, Special Provisions, Hazardous Materials Communications, Emergency Response Information, Training Requirements, and Security Plans
  • 49CFR173, Shippers—General Requirements for Shipments and Packagings
  • Public Health Code Act 368 of 1978, Part 135 Radiation Control

History

Effective date of current version August 15, 2017
Date first adopted June 6, 2000
Revision history August 1, 2001; July 04, 2007; August 15, 2017; May 1, 2018 (format only)
Proposed date of next review May 1, 2021

Authorization

Certified by Responsible Enforcement Official:
/s/ James F. Center
Radiation Safety Officer
July 23, 2018
At the Direction of The Office of the Vice President for Research
/s/ Terri Goss Kinzy
Vice President of Research
July 23, 2018

History

Effective date of current version
Date first adopted
Proposed date of next review

Authorization

At the direction of

The Board of Trustees