Radiation Safety Manual - Chapter 01: UNC-CH Radiation Safety Program

Title

Radiation Safety Manual - Chapter 01: UNC-CH Radiation Safety Program

Introduction

The University of North Carolina at Chapel Hill has been authorized by the State of North Carolina Department of Health and Human Services, Radiation Protection Section, to use radiation sources in operations, education, research and development activities. The UNC-CH Radiation Safety Committee may authorize individual faculty members, as Authorized Users, to use radiation sources after a review of the proposed use, adequacy of facilities, and experience of the applicant. Although this provision allows the University great flexibility in dealing with the multitude of radiation sources and research uses encountered on campus, it places equally great responsibility on investigators and the administration to comply with State regulations so that this flexibility may continue.

This manual summarizes the terms of the University's authorization and the regulations most applicable to campus utilization of various radiation sources. A copy must be available for each Authorized User's facility where radiation sources are used. Special precautions, regulations, and other operating procedures specified by the Radiation Safety Committee or Radiation Safety Officer as a condition for approval of radiation source authorization must also be maintained and made available to laboratory personnel and EHS Safety officers.

Everyone involved with the use of radiation sources in any way is required to be familiar with the provisions of this manual. The manual must be readily available to all interested individuals. All radiation exposure must be maintained to levels that are as low as are reasonably achievable (ALARA).

Responsibilities

Radiation Safety Committee

The Radiation Safety Committee (RSC) is responsible for establishing policies governing the procurement, use, storage and disposal of radioactive materials and radiation-producing devices. The Committee includes individuals experienced in the use or application of radioactive materials and radiation devices and provides a peer review of these uses among researchers at the University. The Committee meets, at least quarterly, to review reports on the receipt and disposal of radioactive materials/radiation-producing devices, and to act on applications for authorization to use these sources. The Committee, along with its Chairman, is appointed by the Chancellor. It makes an annual report of activities to the Vice Chancellor for Finance and Administration.

The Department of Environment, Health and Safety (EHS) has the administrative responsibility for the University's Radiation Safety program. The EHS staff provides a wide range of radiation protection services such as personnel monitoring, waste disposal, laboratory surveys, instrumentation calibrations, maintenance of records required by the State, and consultation on the safe use of radiation sources.

RSC Appointments

The Radiation Safety Committee (RSC) and its chairman are appointed by the Chancellor for three-year terms. Among the members of the committee should be such persons as a representative of the University administration and members of the faculty trained and experienced in the safe use of the major types of radioactive materials and radiation producing devices. The Radiation Safety Officer (RSO) and the Director of the Department of Environment, Health & Safety serve as ex-officio members.

RSC Function

The RSC shall have the responsibility for establishing policies governing the procurement, use, storage and disposal of radioactive materials under the licenses granted to UNC-CH and for devices producing ionizing radiation. The committee shall have the authority and responsibility for approval or disapproval of all proposals for radioactive materials use, and it shall provide a peer review of the use of radioactive materials and radiation producing devices at the University.

The RSO is responsible for the implementation of policies established by the RSC and is responsible for assuring compliance with regulatory requirements. The RSC shall monitor the activities of the radiation protection program to determine that its policies and regulatory requirements are being adequately implemented. This monitoring activity will normally be based upon reports submitted to the committee by the RSO, at the initiative of the RSO or upon request by the committee. The committee shall also have the authority to inspect records of the procurement, use, storage and disposal of radioactive materials and radiation producing devices.

The committee shall meet as needed and at least quarterly to:

  1. Ensure that adequate procedures are developed for the procurement, use, storage and disposal of radioactive materials and radiation producing devices;
  2. Act upon applications for authorization to use radioactive materials and radiation producing devices;
  3. Review reports on noncompliance of the use of radioactive materials and radiation producing devices at the University and take action as required to obtain compliance with University and regulatory requirements or revoke authorization for the use of the radioactive materials or radiation producing devices;
  4. Review and act upon periodic reports on the receipt and disposal of radioactive materials;
  5. To review the ALARA program:
    1. The RSC will encourage all Authorized Users (AU) to be familiar with current use and safety procedures and make revisions as appropriate to implement the ALARA concept.
    2. The RSC will review quarterly occupational radiation exposure, particularly when the investigational levels (Section VIII, MONITORING, Statement 1) are exceeded. Any trends in occupational exposure will serve as an indicator of the ALARA program effectiveness and action guide when investigational levels are exceeded.
    3. The RSC will evaluate the overall efforts for maintaining doses ALARA on an annual basis.
  6. Review and act upon periodic reports on monitoring, contamination and personnel exposure;
  7. Advise, when deemed appropriate by the committee, the Vice Chancellor for Division of Finance and Operations on the hiring of an RSO and on the resources required for the proper operation of the radiation safety program.

A simple majority of the committee membership shall constitute a quorum.

RSC Reports

The committee will submit an annual report to the Chancellor via the Vice-Chancellor and Associate Vice-Chancellor in the Division of Institutional Integrity and Risk Management. The committee shall also report to the Associate and Vice-Chancellor any event or situation relating to radiation which in the judgment of the committee might place the University's license in jeopardy.

Organizational Chart for the Authorization to Use Radiation Sources

Organizational Chart for the Authorization to Use Radiation Sources















 

The Radiation Safety Officer is responsible for radiation protection on this campus, including general surveillance of overall activities involving radiation sources and all areas where sources are used; determining compliance with rules and regulations, authorization conditions and the conditions of project approval specified by the Radiation Safety Committee; consulting on radiation protection with University staff; determining the need for and evaluation of personnel monitoring; conduction of training programs and otherwise instructing personnel in the proper procedures for the safe use of radiation sources; and immediately terminating any project that is found to be a threat to health or property.

All applications for radiation source use, location, procedures, and possession limit changes are reviewed by the Radiation Safety Officer. The Radiation Safety Officer may grant limited interim approval of those applications satisfying all appropriate requirements. The Radiation Safety Officer recommends final action on applications to the Radiation Safety Committee.

Radiation safety courses are given by the Radiation Safety Office every month for employees who will begin working with radiation sources. A schedule may be obtained from EHS. Other specialized training and consultation can also be arranged by appointment.

An Authorized User (AU) is a faculty member who has been approved to use radiation sources according to the procedures developed by the Radiation Safety Committee. The Authorized User will normally be the principal investigator of a research project involving radiation sources or the faculty member responsible for a course with laboratory or field exercises in which sources are used. Although faculty members may use radiation sources under another faculty member's authorization, each faculty member is encouraged to obtain his/her own authorization. It is the Authorized User's responsibility to insure that students and staff using radiation sources under his/her authorization are trained in safe laboratory practices, are familiar with the terms of the authorization and do, in fact, comply with University policies and applicable regulations.

Request for Special Safety Investigation

The North Carolina Radiation Protection Section makes provisions for employees to request an inspection or evaluation of conditions that they believe may constitute a health or safety hazard. University employees are encouraged to report such conditions to EHS and to request a "Special Investigation" into the need for corrective action. University employees who are aware of a health hazard or unsafe condition should notify EHS, 1120 Estes Drive Extension, CB# 1650, or call 962-5507. Employees are encouraged to seek resolution of a hazardous condition through EHS. A person requesting an inspection by EHS or the NC Radiation Protection Section may request confidentiality and by law, his/her name will not appear on any record published, released, or made available to the public, to his/her immediate supervisor, or department head.

After EHS has concluded its investigation, the results will be communicated, in writing, to the party requesting the investigation and to other appropriate University personnel with due consideration of requests for anonymity. If it is determined that there are reasonable grounds to believe that violation or danger exist, corrective action will be initiated. If corrective action cannot be implemented within a reasonable period EHS may terminate the operations until corrective action is taken.

Back to Chapter Zero (Emergency Numbers and Preface)

Proceed to Chapter Two

Details

Article ID: 132052
Created
Thu 4/8/21 9:22 PM
Modified
Tue 9/7/21 1:47 PM
Effective Date
If the date on which this document became/becomes enforceable differs from the Origination or Last Revision, this attribute reflects the date on which it is/was enforcable.
10/02/2020 10:19 AM
Issuing Officer
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Title of the person who is primarily responsible for issuing this policy.
Executive Director
Last Review
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10/02/2020 10:19 AM
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10/02/2020 10:19 AM
Origination
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04/01/2014 12:00 AM
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Environment, Health and Safety