2014
Radiation Safety Manual
Integrated Risk Management
To ensure that all information is the most
up-to-date, no forms or SOPs are included
in this manual but rather a link to their
location on the IRM website is provided
from which they can be directly filled-out
and/or downloaded
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TABLE OF CONTENTS
TABLE OF CONTENTS .......................................................................................................................................................... 3
LIST OF TABLES ................................................................................................................................................................... 6
LIST OF FIGURES ................................................................................................................................................................. 6
1.
2.
ADMINISTRATION AND RESPONSIBILITY ......................................................................................................................... 7
1.1.
Scope ............................................................................................................................................................ 7
1.2.
Authority and Responsibility...................................................................................................................... 7
1.3.
Legislation and Guidance Documents .................................................................................................. 7
1.4.
Stakeholder feedback mechanisms ...................................................................................................... 8
1.5.
Radiation Safety Officer .......................................................................................................................... 10
1.6.
Department Chairs ................................................................................................................................... 10
1.7.
Permit Holders............................................................................................................................................ 10
1.8.
Individuals Working with Radionuclides ............................................................................................... 11
SETTING UP A LABORATORY FOR UNSEALED RADIOACTIVE MATERIALS ......................................................................... 12
2.1.
Top 5 Requirements.................................................................................................................................. 12
2.2.
Approval and Design of Radionuclide Laboratory Locations ......................................................... 12
2.3.
Ryerson Radiation Permit Requirements .............................................................................................. 13
2.3.1 Projects involving more than 10000 Exemption Quantities of a radionuclide ............................. 14
2.4.
2.4.1.
Personal Dosimetry ........................................................................................................................... 14
2.4.2.
Permissible Doses .............................................................................................................................. 15
2.4.3.
Internal Contamination – Bioassay Requirements ..................................................................... 16
2.5.
Selection of Radiation Detection Equipment ..................................................................................... 16
2.5.1.
Dose Rate Monitoring (External Radiation Levels) ..................................................................... 16
2.5.2.
Contamination Monitoring (Amount of Radioactive Material) .............................................. 17
2.6.
3.
Occupational Exposure Monitoring ...................................................................................................... 14
Training Requirements ............................................................................................................................. 17
STANDARD OPERATING PROCEDURES FOR LABORATORY WORK ................................................................................. 18
3.1.
ALARA ......................................................................................................................................................... 18
3.2.
Personal Protective Equipment.............................................................................................................. 18
3.2.1.
Laboratory Coats ............................................................................................................................. 18
3.2.2.
Gloves ................................................................................................................................................. 18
3.2.3.
Safety Glasses/Goggles or Face Shields ...................................................................................... 19
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3.2.4.
Footwear ............................................................................................................................................ 19
3.3.
General Requirements for Work Area Safety ...................................................................................... 19
3.4.
Exposure Monitoring ................................................................................................................................. 20
3.4.1.
Action Levels ..................................................................................................................................... 20
3.4.2.
Bioassay Requirements.................................................................................................................... 21
3.5.
Posting of Required Laboratory Signs ................................................................................................... 22
3.6.
Purchasing Radioactive Materials ........................................................................................................ 25
3.6.1.
3.7.
Procedures for Ordering Radioactive Materials ........................................................................ 25
Transfer of Radioactive Materials .......................................................................................................... 26
3.7.1.
Transfers within the University ......................................................................................................... 26
3.7.2.
Transfers from Outside Institutions.................................................................................................. 26
3.8.
Receipt of Radioactive Packages ........................................................................................................ 26
3.9.
Inventory Control ...................................................................................................................................... 27
3.10.
Storage ....................................................................................................................................................... 27
3.11.
Waste Disposal .......................................................................................................................................... 28
3.11.1.
General .............................................................................................................................................. 28
3.11.2.
Specific Radioactive Waste Streams ........................................................................................... 28
3.11.3.
Aqueous Washes .............................................................................................................................. 29
3.12.
Radiation Detection Equipment ............................................................................................................ 30
3.12.1.
Choice of Instrument ....................................................................................................................... 30
3.12.2.
Efficiency............................................................................................................................................ 31
3.12.3.
Annual Calibration ........................................................................................................................... 31
3.12.4.
Registration ........................................................................................................................................ 31
3.12.5.
Maintenance .................................................................................................................................... 31
3.13.
Radiation Surveys for External Radiation and Contamination ........................................................ 31
3.13.1.
Dose Rate Surveys ............................................................................................................................ 31
3.13.2.
Detection of Surface Contamination .......................................................................................... 32
3.14.
Record Keeping Requirements.............................................................................................................. 36
3.14.1.
Inventory Records ............................................................................................................................ 36
3.14.2.
Contamination Monitoring ............................................................................................................. 36
3.14.3.
Waste Records .................................................................................................................................. 36
3.14.4.
Training Records ............................................................................................................................... 36
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3.14.5.
Inspection Records .......................................................................................................................... 37
3.14.6.
Sealed Source records .................................................................................................................... 37
3.14.7.
Calibration Records ......................................................................................................................... 37
3.15.
Work Practices for Specific Radionuclides .......................................................................................... 37
3.15.1.
Low Energy Beta Emitters ................................................................................................................ 37
3.15.2.
High Energy Beta Emitters ............................................................................................................... 38
3.15.3.
Gamma Emitters............................................................................................................................... 38
3.16.
Sealed Sources.......................................................................................................................................... 39
3.16.1. Leak testing for sealed sources of 50 MBq (1.35 mCi) or more .................................................... 39
3.17.
Decommissioning Rooms ........................................................................................................................ 40
3.18.
Ryerson Radiation Permit Revisions ....................................................................................................... 41
3.18.1.
Amendments .................................................................................................................................... 41
3.18.2.
Renewals ............................................................................................................................................ 41
3.18.3.
Sabbatical/Extended Leave.......................................................................................................... 41
3.18.4.
Inactive Status................................................................................................................................... 42
3.18.5.
Suspension/Revocation .................................................................................................................. 42
3.18.6.
Expiry/Termination ............................................................................................................................ 42
3.19.
4.
Self-Audit Checklist – Top 10 Things to Remember ............................................................................ 42
SECURITY ................................................................................................................................................................. 43
4.1.
Authorized Access .................................................................................................................................... 43
4.2.
Maintaining Security................................................................................................................................. 43
4.3.
Bringing Radioactive materials on Campus ....................................................................................... 43
4.4.
Missing Radioactive materials ................................................................................................................ 43
5.
EMERGENCY PROCEDURES ....................................................................................................................................... 43
6.
REFERENCES ............................................................................................................................................................ 46
6.1.
Regulatory Agencies ............................................................................................................................... 46
6.2.
Professional Radiation Safety Associations .......................................................................................... 47
APPENDIX A ................................................................................................................................................................ 48
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LIST OF TABLES
Table 1. Classification of Basic and Intermediate Rooms for Various Isotopes ............................................. 13
Table 2. Radiation Exposure - Annual Limits ......................................................................................................... 15
Table 3. Action Levels for Individual Doses ........................................................................................................... 21
Table 4. Action Levels for Bioassay Monitoring .................................................................................................... 22
Table 5. Requirements for Laboratory Signs ......................................................................................................... 24
Table 6. Exemption quantities for selected radionuclides ................................................................................ 25
Table 7. Radioactive Waste Disposal Criteria for Individual Radioisotopes ................................................... 30
Table 8. Action Levels for Removable Surface Contamination in Controlled Areas for Selected
Radioactive materials .............................................................................................................................................. 32
Table 9. Decontamination Methods for Removable Surface Contamination ............................................. 35
Table 10. Classification of Selected Radioactive materials for Removable Surface Contamination
Levels in Decommissioned or Public Areas .......................................................................................................... 40
Table 11. Classification of Minor Spills for Selected Radionuclides.................................................................. 44
Table 12. Procedures for Decontamination of Contaminated Personnel ..................................................... 45
LIST OF FIGURES
Figure 1. Organization/Reporting Structure at Ryerson University ..................................................................... 9
Figure 2. Thermoluminescent dosimeter showing internal lithium fluoride chip ............................................ 14
Figure 3. Radioactive Warning Sign ....................................................................................................................... 24
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1. ADMINISTRATION AND RESPONSIBILITY
1.1. Scope
These procedures form part of the Radiation Safety Program and apply to all faculty, staff and
students using, receiving, possessing, working and disposing open radioactive sources in all areas and
facilities controlled by Ryerson University. The Canadian Nuclear Safety Commission issues Ryerson
University a Consolidated Licence for all its radioactive materials. The license allows Ryerson University
to possess, store and use specified radioactive materials. The Radiation Safety Program outlines the
regulatory requirements in observance with this license and associated legislation.
1.2. Authority and Responsibility
The University shall establish a Radiation Safety Program for ionizing radiation producing open sources
in accordance with Canada’s Nuclear Safety and Control Act and applicable regulations and
regulatory documents, administered by the Canadian Nuclear Safety Commission. All occupational
exposures to ionizing radiation shall be limited in accordance with the ALARA principle (As Low As
Reasonably Achievable) and within legislated prescribed dose limits. Ryerson University’s Radiation
Safety Program is designed to keep exposures ALARA through training and implementation of
standard operating procedures and protocols to control the storage, handling and disposal of
radioactive materials.
Responsibility for controlling all activities related to ionizing radiation safety at Ryerson University rests
with the offices of the Provost and Vice President Administration and Finance. Their authority in this
regard is received from the President of Ryerson University.
Details of the enforcement policy are outlined in Appendix A.
1.3. Legislation and Guidance Documents
All radioactive materials are regulated under the jurisdiction of various acts and regulations under the
Canadian Nuclear Safety Commission (CNSC), including the Nuclear Safety Control Act, almost 75
regulations and guidance documents, and a Consolidated Licence issued by the CNSC to the
University. The Consolidated Licence allows Ryerson University to purchase, possess, use, store and
dispose of radioactive materials, provided all the conditions of the Licence are followed.
This type of licence allows the University flexibility for managing its own radiation protection program.
However, because it is a single licence, all actions impact on the licence's viability. In other words, if a
serious event in one location were to occur, this single licence may be jeopardized which would
affect work throughout the entire University.
Copies of all relevant CNSC Acts, regulations, and guidance documents are available via the
Radiation Safety Officer or through the department's website (www.ryerson.ca/irm) under the
Radiation Safety Program.
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1.4. Stakeholder feedback mechanisms
In order to receive advice and direction on radiation safety matters, all stakeholders (permit holders,
technical staff, and other parties involved such as Faculty, Deans/Directors implicated or specialized
in radiation-related fields) are encouraged to provide feedback to the RSO who will collect and
report back to the VP Administration and Finance and Provost. Every year, a report will go out to all
permit holders, the VP Administration & Finance, and Provost. This reports is prepared by the RSO and
will include the following statistics:
•
•
•
•
•
•
•
Number of new permits
Number of permit renewals/updates
Number of individuals trained
Inspection results
List of licence amendments (if any)
Updates to CNSC act or regulations
List of stakeholders' comments/advice/requests and follow-up
The current organizational structure for radiation safety at Ryerson University is shown in Figure 1 below.
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Figure 1. Organization/Reporting Structure at Ryerson University
President
Vice President
Administration & Finance
Provost
Vice President
Research & Innovation
Director
Integrated Risk Management
Deans
Assistant Director
Risk Management & Prevention
Chairs & Academic Directors
Radiation Safety Officer
Permit Holders
Users
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1.5. Radiation Safety Officer
The position of Radiation Safety Officer receives its authority from the Vice President, Administration &
Finance, through the Director, Integrated Risk Management and the Associate Director, Risk
Management & Prevention of Ryerson University. The Radiation Safety Officer is responsible for
coordinating all activities related to radiation safety, and for making recommendations to the Vice
Presidents, through the Assistant Director, Risk Management & Prevention, regarding the control of all
activities related to radiation safety. The Radiation Safety Officer is responsible for coordinating the
daily activities of the Radiation Safety Program. Annual reports to the Canadian Nuclear Safety
Commission will be prepared and submitted on behalf of the University by the Radiation Safety
Officer. The RSO also has the duty to report, upon having been made aware of , any incident or
situation defined in Section 29 of the General Nuclear Safety and Control Regulations and file a full
report of the situation within 21 days, unless some other period is specified in the licence, and this
report shall contain the following information:
•
•
•
•
•
•
the date, time and location of becoming aware of the situation;
a description of the situation and the circumstances;
the probable cause of the situation;
the effects on the environment, the health and safety of persons and the maintenance of
security that have resulted or may result from the situation;
the effective dose and equivalent dose of radiation received by any person as a result of the
situation; and
the actions that have been taken or proposed to be taken with respect to the situation.
1.6. Department Chairs
For areas using radioactive material(s), each departmental chair is responsible for providing
adequate facilities, equipment, instruments, supervision to control radiation hazards and to comply
with the University’s radiation protection requirements. And ensure that faculty, staff and students
receive proper training.
1.7. Permit Holders
Each individual who directs and supervises the use of unsealed radioactive materials is responsible for
complying with the requirements outlined in the Canadian Nuclear Safety Commission, licences
issued to the University, as well as with any additional requirements prescribed by internal procedures
contained in the Radiation Safety Program. This individual will required to obtain an internal permit for
the use of unsealed radioactive materials and will be deemed to be a Permit Holder.
NOTE :
Strict adherence to the conditions of approval for each and every internal permit is critical. Failure to
comply will not only result in cancellation of individual permits but will seriously jeopardize the
continuance of the University’s Consolidated Licence.
Each Permit Holder is responsible for:
a) Following the conditions as stated in the permit and that safe laboratory practices as stated in
the standard operating procedures as prescribed by the Radiation Safety Program.
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b) Ensuring all staff using radioactive materials have been trained regarding the policies,
procedures and programs on the safe use of radioactive materials at Ryerson University and
are authorized to use radioactive materials.
c) Ensuring that students using radioactive materials are properly supervised and ensuring they
receive instruction in the safety procedures and University protocols on the safe handling of
radioactive materials.
d) Ensuring that all staff, students and researchers participate in required radiation safety training.
e) Ensuring that designating work and storage areas for radioactive materials are maintained in
proper working order, kept clean, properly labelled, are adequately shielded and that existing
ventilation is not impaired.
f) Ensuring that all staff working with radioactive materials have been issued, and wear a
thermoluminescent dosimeter and participate in the bioassay program, as required.
g) Ensuring that any radiation monitoring equipment used by the laboratory staff is adequate to
the task and functioning properly.
h) Allowing only authorized persons to enter rooms that are specified as restricted areas for
reason of ionizing radiation protection.
i) Maintaining an up to date inventory of all radiation sources (isolated sources or sources
incorporated into equipment). This is to include a listing of the rooms in which radioactive
materials are located or used. http://www.ryerson.ca/irm/forms/index.html provides a
standard inventory form (different form for Sealed Vs Unsealed sources).
j) Reporting to the Radiation Safety Officer any incidents involving abnormal activities such as
loss of materials, suspected exposures to ionizing radiation exceeding permissible standards.
k) Ensuring that all radioactive materials are properly stored.
l) Coordinating all purchases, acquisitions, transfers and disposal of radioactive materials, sealed
sources and devices containing such sources with the Radiation Safety Officer, prior to any
arrivals or movement off campus.
m) Notifying the Radiation Safety Officer whenever the permit holder will be unavailable to
supervise, identifying another permit holder who has accepted the responsibility as the
temporary supervisor.
1.8. Individuals Working with Radionuclides
All persons working with unsealed radioactive materials have certain responsibilities. These are:
a) Working in compliance with all policies, procedures and requirements at the University using
protective and/or monitoring equipment required for the safe use of radioactive materials.
b) Reporting to the Permit Holder any defective equipment, violation or situation that may
endanger a worker or create an unauthorized release of radioactive materials to the
environment.
c) Not creating or participating in any activity which may endanger themselves, any other
worker or create the potential for unauthorized release of radioactive materials to the
environment.
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2. SETTING UP A LABORATORY FOR UNSEALED RADIOACTIVE MATERIALS
2.1. Top 5 Requirements
Before any work is performed with unsealed radioactive materials, advance preparation is required
to set up equipment, and implement regulatory and administration protocols. Here are the top five
items that are required to be completed before the first isotope is purchased:
1. LAB DESIGN
a) Approval of radioisotope laboratory design and classification of containment level
2. RADIATION PERMIT
a) Submitting an application and receiving approval for a Ryerson Radiation Permit
3. EXPOSURE MONITORING
a) Depending on the activity and type of isotope(s) used, occupational exposure monitoring for
all lab personnel that will be working with radioisotopes may be required:
i. For high energy beta emitters (e.g.P-32) and gamma emitters (e.g. Cr-51, I-125, I-131) an
application for TLD badge must be submitted and a badge assigned and received from
the Radiation Safety Officer
ii. Where applicable, bioassays for radioiodines or low energy beta emitters such as H-3 may
be required.
4. EQUIPMENT
a) Radiation detection equipment is required to monitor surface contamination and in some
cases external dose rate.
5. TRAINING
a) Laboratory staff, from principal investigator to summer student, will not be allowed to use
unsealed radioactive materials or order materials without appropriate training. Training will be
mandatory prior to the issuing of any TLD badge. Training requirements may vary – consult
Radiation Safety Officer.
b) Below is a more comprehensive explanation for each topic that expands on the requirements.
2.2. Approval and Design of Radionuclide Laboratory Locations
All areas including laboratories, storage areas, counting rooms, etc, where the use of radioactive
materials is proposed must be approved by the Radiation Safety Officer prior to radioactive materials
being used or stored. All rooms intended to be used for the handling, storage or disposal of a
radioactive material must conform to the requirements of Canadian Nuclear Safety Commission
(CNSC) Regulatory Guide R52 (Rev 1) Design Guide for Basic and Intermediate Level Radioisotope
Laboratories, or updated regulation :
http://nuclearsafety.gc.ca/eng/acts-and-regulations/regulatory-documents/index.cfm
If a laboratory has not been previously approved, it will require an inspection by the Radiation Safety
Officer before any use of radioactive materials is permitted in the laboratory.
The Canadian Nuclear Safety Commission (CNSC) regulates the classification of rooms, based on the
amounts of activity (and by isotope) in each room. A radioisotope laboratory is classified as Basic
Level, Intermediate Level, High Level, or Containment Level.
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Laboratory classification is based on the radioactive material to be handled in the laboratory. For
Basic Level Rooms, the Radiation Safety Officer will authorize the area and designate the room. For
proposed work in laboratories with activities greater than listed for a Basic-Level Room, the University
requires written approval from the CNSC for every higher containment areas (i.e. Intermediate-Level
Rooms or greater levels of containment). Table 1 outlines the classification of basic and intermediate
rooms for a few of the most common radioisotopes.
Table 1. Classification of Basic and Intermediate Rooms for Various Isotopes
Isotope
Exemption
Quantity
(MBq)
a
ALI
(MBq)
b
Basic Level
Intermediate Level
(≤ 5 ALI per container)
(>5 & ≤ 50 ALI)
MBq
b
MBq
mCi
mCi
C-14
10
34
170
4.6
1700
46
Cr-51
10
530
2650
71.6
26,500
716
1000
1000
5000
135.1
50,000
1351
I-125
1
1.3
6.5
0.2
65
2
P-32
0.1
6.9
34.5
0.9
345
9
P-33
100
15
75
2.0
750
20
S-35
100
26
130
3.5
1300
35
H-3
Source link: the nuclear substances and radiation devices licence application guide
Notes:
a) ALI ( Annual Limit on Intake) means the quantity, in Becquerels of a radionuclide which, when taken into the body, will deliver an
effective dose of 20 mSv over the 50 years following its intake. Only the most restrictive ALI is listed here (either Inhalation or
Ingestion)
b) 37 MBq = 1 mCi
If multiple radioisotopes are proposed to be used in the same location, then the proposed laboratory
would be classified according to the most restrictive quantity. For example, if a researcher intends to
use 150 MBq of Sulphur-35, 37 MBq of Tritium and 37 MBq of Carbon-14, the radioisotope laboratory
would be required to be classified as an intermediate level laboratory due to the quantity of Sulphur35 present and will require written approval from the CNSC. No permit can be issued until this
approval has been received.
Depending on designation of the Level of Classification, CNSC lab posters will be required to be
posted as well. These are available through the RSO, who must assign the lab classification based on
the permit application/update information provided by the permit holder.
2.3.Ryerson Radiation Permit Requirements
A Ryerson Radiation Permit issued by the University is required for any purchase, possession and use of
radioactive material. A prospective user of open sources of radioisotopes must obtain an internal
radioisotope permit before any radioactive material is brought onto the campus. This applies to all
acquisitions of radioactive material, whether purchased, transferred, or donated. Apply on-line for a
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permit at: https://ccs.cf.ryerson.ca/cehsm/portalv2/ or contact the Radiation Safety Officer if the
system is not available for any reason.
Applications for an internal RU Radiation Permit are reviewed and approved by the Radiation Safety
Officer on behalf of the University. Permits are normally only issued to professorial or other approved
staff having documented training and at least two years of experience in the use of radioisotopes.
The term of the permit is at the discretion of the University, but cannot exceed the term of the CSNC
issued Consolidated Licence. A copy of the most recent permit must be posted by the permit holder
in each location listed on the permit. Radioactive material may not be used, stored, or disposed in a
location not listed on the permit. Once a permit has been issued, there may be no changes to the
facilities used, isotopes and quantities allowed without prior approval from the University. An internal
permit does not normally cover off-campus use of radioactive materials. A special and separate
approval will be required from the University.
2.3.1 Projects involving more than 10000 Exemption Quantities of a radionuclide
In addition, written approval will be required from the Canadian Nuclear Safety Commission for any
single use with more than 10,000 exemption quantities (EQ) of any radionuclide. In these cases, the
actual research protocol must be approved by the CNSC. Refer to Table 1 for a listing of exemption
quantities for common radionuclides. For radionuclides not listed in Table 1, please contact the
Radiation Safety Officer.
2.4. Occupational Exposure Monitoring
2.4.1.
Personal Dosimetry
Exposure monitoring with personal dosimeters monitors an individual’s exposure history by recording
the cumulative dose received from occupational exposure to high energy radiation sources. TLDs
have a lithium fluoride chip which records the exposure to ionizing radiation. The badges are worn at
chest or waist levels to record whole body exposure. Information obtained from exposure reports is
useful to evaluate the effectiveness of protective measures and to prevent over-exposure.
When working with a gamma or high energy beta emitter, a thermoluminescent dosimeter (TLD)
badge is required to be worn. Depending on the proposed isotope and activity, a ring dosimeter
may also be required to monitor extremity exposures. For example, P-32 users working with activities
greater than 37 MBq, will be required to wear a ring dosimeter.
Figure 2. Thermoluminescent dosimeter showing internal lithium fluoride chip
All dosimetry is coordinated through the Radiation Safety Officer. The Radiation Safety Officer will
determine the extent of dosimetry required. In order to receive a personal dosimeter, an application
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form must be submitted to the Radiation Safety Officer for every individual planning to work with
radioactive materials, prior to any work commencing. All information is considered confidential but is
required to register new individuals with the National Dosimetry Services (NDS) in the Radiation
Protection Branch of Health Canada. Badges are issued and processed by the National Dosimetry
Services (NDS) where the records of exposure are maintained by the NDS.
New badges to individuals are assigned and issued by the Radiation Safety Officer. A blank
application form is available at http://www.ryerson.ca/irm/forms/index.html. All monitoring results are
maintained and evaluated by the Radiation Safety Officer. Refer to Section 3.4 and
http://www.ryerson.ca/irm/programs_policies/radiation.html under Standard Operating Procedures for
the proper use and storage of TLD badges.
TLDs are insensitive to weak beta emitters such as Tritium (H-3), Sulphur 35 (S-35) and Carbon 14 (C-14),
and therefore TLD badges are ineffective. Refer to Section 2.4.3 for monitoring for these isotopes.
2.4.2.
Permissible Doses
2.4.2.1. General Public
The exposure from sources of ionizing radiation shall normally be controlled in such a way as to
provide assurance that no individual or user shall receive an absorbed dose in excess of the values
outlined by the CNSC and listed in Table 2.
Table 2. Radiation Exposure - Annual Limits
Member of the Public/ Non-NEW
Whole Body
Nuclear Energy Worker (NEW)
Annual (mSv)
Pregnant (mSv)
Annual (mSv)
Pregnant (mSv)
1
1
20
20
4 over 9 months
Extremities
50
50
500
500
Lens of the Eye
15
15
150
150
Skin
50
50
500
500
(hands & feet)
Source: http://laws-lois.justice.gc.ca/eng/regulations/SOR-2000-203/
2.4.2.2. Nuclear Energy Workers
a) Under the Nuclear Safety and Control Act, a “Nuclear Energy Worker” (NEW) means any
person who in the course of his work, business or occupation, is likely to receive a dose of
ionizing radiation in excess of the annual dose to the general public specified in Table 2. Each
person who, in the opinion of the Radiation Safety Officer, may be exposed to external or
internal radiation from sources (except prescribed medical treatment) in excess of the limits for
a member of the public as listed in Table 2, will be classified as a Nuclear Energy Worker. Those
individuals classified as a NEW will be required to sign an acknowledgement of their
classification.
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b) Any pregnant worker designated as a Nuclear Energy Worker must inform the Radiation Safety
Officer, in writing, as soon as she is aware of her condition. The dose rate to a pregnant NEW
may not exceed 0.25 mSv over 2 weeks to a maximum of 4 mSv for the period of her
pregnancy.
2.4.3.
Internal Contamination – Bioassay Requirements
Thermoluminescent dosimeters do not monitor exposure to low energy beta emission isotopes (e.g. H3, C-14). Workers using such isotopes may be required to participate in the bioassay program and
submit biological samples for monitoring of radioisotopes. In addition, handling radioiodines such as
Iodine 131 (I-131) and Iodine 125 (I-125) may require additional biological monitoring.
Biological monitoring uses bioassay techniques to determine the amount of a particular radioisotope
in the body. Two methods can be used for carrying out a bioassay technique - in vitro and in vivo. In
vitro techniques are used when a small sample of a body fluid or tissue is sampled and analyzed in a
detector. This is the technique used when urine is monitored for assessing tritium uptake. In vivo
techniques involve measuring the amount of radioactive material by placing detectors close to the
surface of the body. This technique is used for assessing the uptake of radioiodine in the thyroid. Refer
to Section 3.4 for action limits for bioassay requirements.
The Ryerson Radiation Permit will stipulate the conditions under which a bioassay is required. The
frequency of the bioassay monitoring is dictated by the activity of the radioisotope. It is the
responsibility of the Permit Holder to ensure that bioassay monitoring is carried out when required by
the conditions outlined in the Ryerson Radiation Permit. Contact the Radiation Safety Officer to
arrange for a bioassay measurement.
2.5. Selection of Radiation Detection Equipment
Appropriate radiation detection equipment must be obtained by the Permit Holder and made
available to laboratory staff working with radioactive materials.
Depending on the isotope and activity proposed to be used in laboratory work, Permit Holders may
be required to carry out two different radiation surveys for:
1. External radiation levels
2. Surface contamination
The ability of various radiation detection instruments to detect radionuclides of interest will vary with
the instrument and manufacturer. Instrument sensitivity for direct reading portable instruments must be
capable of making reproducible measurements at the criteria limits. The Radiation Safety Officer shall
be contacted for guidance on the selection of instruments.
2.5.1.
Dose Rate Monitoring (External Radiation Levels)
It is a requirement for researchers working with high energy beta emitters such as Phosphorus-32 (P-32)
and gamma emitters such as Chromium-51, Iodine-125, etc, to be able to determine dose rates.
Survey meters will be required to survey incoming packages and monitor radiation levels around the
work space, storage and disposal areas for such isotopes. Detectors with ion chambers are very
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efficient. Geiger Mueller (GM) counters can also be used. A GM counter can measure radiation at
lower radiation levels and is less expensive than a survey meter with an ion chamber detector.
It is a requirement of the CNSC to have dose rate survey meters calibrated annually. Contact the
Radiation Safety Officer to make arrangements.
2.5.2.
Contamination Monitoring (Amount of Radioactive Material)
Monitoring for surface contamination from unsealed radioactive materials will be required by all Open
Source Permit Holders. Radioactive contamination may be measured directly or indirectly.
Direct measurements use portable radiation detection instruments to detect both fixed and
removable surface contamination. Direct measurement may be used when background radiation
levels are negligible and the detector has sufficient sensitivity. To monitor large areas, it is more
convenient to use a direct reading instrument, if it is suitable for the isotope being surveyed (ask the
RSO).
Indirect measurement of contamination is used when portable instruments are not sensitive enough or
when the radiation background is too high. Indirect methods can only be used to monitor removable
contamination. The higher efficiency, low background and multiple sample counting makes them
ideal for contamination survey work. The most effective means of monitoring for surface
contamination is through the use of swipes and liquid scintillation counting. Swipe tests only detect
removable contamination. Low energy beta emitters (e.g. H-3, C-14 and S-35) have a very low
efficiency for portable survey meters, and are best detected through the scintillation counting
method.
All radioisotope laboratories, except those exclusively using tritium (H-3), will have available a
functioning portable instrument for contamination. Most laboratories will use a meter with a pancaketype Geiger-Muller (GM) probe. These detectors are useful for detecting the spread of contamination
but Geiger counters have poor detection efficiency for gamma emitters, weak beta emitters, and
cannot detect tritium. For high energy gamma emitters, a thick (2 or 3 mm) sodium iodide detector is
best and for low-energy gamma emitters such as I-125, a detector with a thin (1 or 2 mm) sodium
iodide scintillation crystal must be used. For low energy beta emitters like C-14 and tritium, only indirect
methods can be used, such as liquid scintillation counting. Liquid scintillation counting is also good for
all radionuclides. Discuss with the RSO to find the best method of detection for your particular needs.
2.6. Training Requirements
The CNSC requires that all persons working with radioactive material obtain training in the safe
handling of radioactive material prior to beginning work with the radioactive material. This training
must include information on the risks associated with exposure to ionizing radiation, the safe use,
handling, storage and disposal of radioactive material.
It is the responsibility of the permit holder to ensure that all personnel working with radioactive
materials under the permit holder’s permit receive the appropriate training and know the proper
policies and procedures for the use of radioactive materials before beginning work. Permit Holders are
responsible to supervise and document the hands-on laboratory training involving experimental
procedures, techniques and equipment used in working with radioactive materials.
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The Radiation Safety Officer may exempt a person from the requirement to complete the Radiation
Safety Course offered by Integrated Risk Management if the individual can provide proof of
successful completion of an equivalent course at another institution or facility. However, all persons
must be familiar with the policies and procedures in force at Ryerson University and successfully
complete an examination before starting any work with radioactive materials.
Participants who have successfully completed the examination are designated as authorized users
and allowed to work with radioactive materials without direct supervision. Summer students or other
temporary employees are also required to be trained before beginning work with radioactive
materials. However, they may not work with radioactive materials without direct supervision by
someone who has successfully completed the regular training course and examination.
Permit Holders will be required to participate in refresher training every five years and all other
radioisotope users such as staff and students will be required to participate in refresher training within
a period of three to five years.
3. STANDARD OPERATING PROCEDURES FOR LABORATORY WORK
3.1. ALARA
It is the policy of the University to maintain all occupational exposures to ionizing radiation in
accordance with the ALARA principle. ALARA is an acronym for As Low As Reasonably Achievable.
This takes into account the regulatory dose limits, social and economic factors being taken into
consideration to ensure that every possible effort is used to keep radiation exposures as far below the
regulated dose limit as practical. All occupational exposures to ionizing radiation shall be limited in
accordance with CNSC legislation and the ALARA principle.
3.2. Personal Protective Equipment
Direct contact with unsealed radioactive materials must be avoided by the proper use of protective
clothing. Disposable items must be placed into radioactive waste disposal containers immediately
after use. As a minimum, this consists of:
3.2.1.
Laboratory Coats
Laboratory coats will be worn fully buttoned and should not be worn outside the active laboratory
working areas. Lab coats may not be worn into non laboratory areas such as any eating areas.
Where possible, coat hooks should be installed near the exit door to encourage laboratory personnel
to remove such clothing before leaving the laboratory.
3.2.2.
Gloves
Disposable, impervious gloves used for radioisotope work must be removed before leaving the
laboratory or after use to prevent the spread of contamination to non radioactive areas (e.g., to
telephones and refrigerator or freezer door handles).
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3.2.3.
Safety Glasses/Goggles or Face Shields
Safety glasses/goggles are required for any work involving unsealed radioactive materials. It is
recommended that contact lenses not be worn in a laboratory.
3.2.4.
Footwear
Open-toed shoes are not permitted when handling unsealed radioactive materials.
3.3. General Requirements for Work Area Safety
a) There shall be no smoking, drinking, eating or storage of food or food containers in any fridge,
freezer or other areas used to contain radioactive materials.
b) All personnel are expected to practice ALARA in their work practices. Each Permit Holder must
implement procedures designed to reduce exposures to radiation to ALARA.
c) Prior to conducting a new procedure involving radioisotopes, a test run using non-radioactive
material should be carried out to test the procedure.
d) Use the minimum quantity necessary to satisfy the objective of the procedure.
e) Where ever possible, the handling of radioactive materials shall be restricted to a one area of
the laboratory (e.g. dedicated bench area). The work area must be covered with disposable
absorbent materials (e.g. bench covering material), which must be immediately discarded if
radioactive material has been spilled. Disposable absorbent material must be replaced on a
regular basis.
f) External exposures to radiation will be minimized through the appropriate use of shielding
material, increasing the distance from the radioactive source and reducing the time spent
working with the nuclear substance.
g) Internal exposures are minimized by preventing INGESTION, INHALATION, and ABSORPTION
through the skin, by implementing proper work safety procedures.
h) All equipment and other items used during a radioisotope procedure must be labelled with
appropriate radiation warning labels.
i) Where feasible, this equipment should be stored in a separate area away from general
laboratory use. Before being returned to general use, all equipment must be properly
decontaminated. Warning labels must be removed when the item has been
decontaminated.
j) Where possible, only one sink should be used for the washing of contaminated glassware and
equipment. This sink should be clearly labelled with radiation warning signs. Glassware
designated for work with radioactive materials should be washed separately.
k) When not in use, all containers containing radioactive solutions must be covered and labelled
with radiation warning tape, the name of the radioisotope and activity.
l) Never pipette radioactive solutions by mouth. A radioactive solution must never be poured
from one container to another, but must be transferred carefully with a disposable pipette or
tip.
m) Radioactive solutions must be transported in such a way as to avoid the spread of radioactive
contamination in the event of breakage (e.g. in an outer plastic beaker or tray lined with
disposable absorbent liner).
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n) Where work with unsealed radioactive materials will result in release of radioactive material
through volatilization, dispersion of aerosols or splatter, the work will be carried out in a fume
hood equipped with an alarming flow monitoring device.
o) All radioisotope work areas must be monitored within seven days of usage. Records of
monitoring and corrective actions must be maintained and available for inspection. Particular
attention should be paid to the floor below the radioisotope work area. Hands and clothing
should be monitored to ensure that no contamination has occurred.
p) Any radiation detector should be kept away from the radioisotope handling areas to prevent
accidental contamination. While materials such as plastic wrap may be used to prevent
contamination of the monitor from routine handling, it must be considered that any material
placed over the detector will reduce the efficiency of the unit and will no longer be adequate
for contamination monitoring purposes.
q) Upon completion of a radioisotope experiment, all materials must be properly labelled. All
material and equipment used during the procedure must be safely stored or prepared for
disposal.
r) Materials used in radioisotope area will be easily decontaminated. Cloth or fabric covered
chairs are not permitted in radioactive work area.
s) All equipment or devices which are to be sent for repair or maintenance must be
decontaminated before being released from the radioactive working area.
t) Before leaving the laboratory, all persons must wash their hands thoroughly.
3.4. Exposure Monitoring
Care should be taken that the dose recorded by the thermoluminescent dosimeter (TLD) badge
and/or ring dosimeter is representative of the true dose to the individual to whom it is assigned. The
dosimeter must not be left in an area where it could receive a radiation exposure when not worn by
the individual (e.g. left near a radiation source). In addition, the lithium fluoride chips inside the TLD
badge are sensitive to light and may produce false results if exposed to ultraviolet, fluorescent lights or
sunlight. Always store your dosimeters in a dark area with a low radiation background. Care should be
taken to maintain dosimeters away from contamination, since this may also result in a false positive
reading. Refer to “Procedures for TLD Badges” at http://www.ryerson.ca/irm/programs_polic
ies/radiation.html under Standard Operating Procedures.
3.4.1.
Action Levels
An action level is defined by the Radiation Protection Regulations under the Nuclear Safety and
Control Act of Canada as “a specific dose of radiation or other parameter that, if reached may
indicate a loss of control of part of a licensee’s radiation protection program and triggers a
requirement for specific action to be taken”. They are compared to the annual exposure limits to
ionizing radiation are set by the Canadian Nuclear Safety Commission (CNSC). The primary goal of the
action to be taken is to prevent a re-occurrence of the event.
Action levels are part of Ryerson’s overall radiation protection program. They are designed to alert
Ryerson faculty, staff and students before regulatory exposure limits are reached. Table 3 outlines the
action limits for individual doses to external radiation and the steps required in the event of an
overexposure. Refer to Ryerson’s Radiation Safety Procedures for Action Levels
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(http://www.ryerson.ca/irm/programs_policies/radiation.html under Standard Operating Procedures)
for more details.
Table 3. Action Levels for Individual Doses
Investigation Level
Action Level
Quarterly
Annually
(mSv)
(mSv)
whole body
Member of Public/ Non-NEW
Nuclear Energy Worker
(NEW)
extremities
whole body
extremities
0.4
10
0.8
10
1
10
10
50
In the event of exposure greater than action levels in Table 3, the Radiation Safety Officer will:
a) Conduct an investigation to establish the cause for reaching the action level
b) Identify and take action to restore the effectiveness of the radiation protection program
c) Notify the Canadian Nuclear Safety Commission within period specified in licence.
In the event of when the CNSC dose limit is exceeded, the Radiation Safety Officer will:
a) Immediately notify the individual and the CNSC
b) Require the affected individual to immediately leave the work that may add to the dose
c) Conduct an investigation to establish an estimate of the dose and the cause for the exposure
d) Within 21 days, report to the CNSC on the progress of the investigation.
3.4.2.
Bioassay Requirements
Thermoluminescent dosimeters do not monitor low energy beta emission isotopes (e.g. H-3, C-14, S35). Workers using such isotopes may be required to participate in the bioassay program (i.e.
biological monitoring) and submit biological samples for monitoring the amount of a specific
radioisotope in the body. In addition, laboratory workers handling radioiodines (e.g. Iodine 131 and
Iodine 125) are also required to participate in the bioassay program. The frequency of the bioassay
monitoring is dictated by the activity and the radionuclide. The Ryerson Radiation Permit will stipulate
the conditions under which a bioassay is required.
Two methods can be used for carrying out a bioassay technique - in vitro and in vivo. In vitro
techniques are used when a small sample of a body fluid or tissue is sampled and analyzed in a
detector. This is the technique used when urine is monitored for assessing tritium uptake. In vivo
techniques involve measuring the amount of radioactive material by placing detectors close to the
surface of the body. This technique is used for assessing the uptake of radioiodine in the thyroid.
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It is the responsibility of the Permit Holder to ensure that bioassay monitoring is carried out when
required by the conditions outlined in the Ryerson Radiation Permit. Contact the Radiation Safety
Officer to arrange for a bioassay measurement.
Table 4. Action Levels for Bioassay Monitoring
Isotope
Iodine
I-125 &
I-131
Bioassay Monitoring
•
> 5 MBq (0.13 mCi) in single use
on open bench
•
OR spill > 5 MBq of volatile
radioiodine in room
•
>50 MBq (1.3 mCi) in fume hood
•
>500 MBq (13 mCi) in glove box
•
external contamination is detected
on the person
•
process where significant intake is
possible
dependent on nature of H-3 (e.g.,
tritiated water vs. compounds, etc),
method of handling (open bench or
fumehood) and quantities
•
Tritium
(H-3)
Frequency
Investigation
Level
24 hours after
use & no later
than 4 days
after use
1 kBq (thyroid)
Action Level
10 kBq
(thyroid)
100 kBq/litre
(urine)
1 MBq/litre
(urine)
In the event of exposure greater than action levels in Table 4, the Radiation Safety Officer will:
a) conduct an investigation to establish the cause for reaching the action level
b) identify and take action to restore the effectiveness of the radiation protection program
c) notify the Canadian Nuclear Safety Commission within specified period of licence.
In the event of when the CNSC dose limit is exceeded, the Radiation Safety Officer will:
a) immediately notify the individual and the CNSC
b) require the affected individual to immediately leave the work that may add to the dose
c) conduct an investigation to establish an estimate of the dose and the cause for the exposure
d) within 21 days, report to the CNSC on the progress of the investigation.
3.5. Posting of Required Laboratory Signs
After receiving a Radiation Permit and work begins with radioactive materials, the rooms where
radioactive materials will be used or stored will require a variety of signage (Summarized in Table 5
below). Frivolous posting of radiation warning signs or labels is prohibited under federal legislation.
a) Internal Permits are required to be posted in a visible location inside all locations listed on
permit. The current staff list must be posted with the permit in the main laboratory of the
permit holder.
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b) A copy of the CNSC Rules for Working with Radioisotopes in a Basic/Intermediate/High Level
Laboratory or updated information must be posted in each room where radioactive material is
handled. Copies may be obtained from the Radiation Safety Officer.
c) Entrances to areas where the effective dose rate is greater than 25 µSv/h (or 2.5 mR/hr) or the
radioactive substance is in a quantity greater than 100 times its exemption quantity (as
outlined in Table 6 below) in the room/area must be marked with a sign (shown in Figure 3)
that has a radiation warning symbol and the words “Rayonnement- Danger - Radiation”. Signs
can be obtained from the Radiation Safety Officer.
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Rayonnement - Danger - Radiation
Figure 3. Radioactive Warning Sign
d) Equipment with more than one (1) exemption quantity (EQ) must have a label with a radiation
warning symbol and the words “Rayonnement- Danger - Radiation”. The name, quantity, date
of measurement and form of the radioactive substance in the container or device. Refer to
Table 6 for some exemption quantities. A more detailed list is available from the Radiation
Safety Officer.
Table 5. Requirements for Laboratory Signs
Location
Information and Type of Posting
Entrance to:
•
Radioactive Warning Sign with Permit Holder name
and office phone #, 24 hour contact number
laboratory, storage area, or other permitted
area with more than 100 EQs
•
Radiation Safety Officer phone #
•
Copy of the Internal Permit
•
Current list of authorized users (inside main lab only)
•
CNSC Safety poster for appropriate Lab category
•
Radioactive Warning Sign
•
Indicate dose rate if > 2.5 µSv/h at contact
•
Radioactive Warning tape identifying work area
Inside the lab, in a prominent location
Storage Location
Work Area
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Table 6. Exemption quantities for selected radionuclides
Radionuclide
Exemption Quantity (Bq)
Exemption Quantity (µCi)
4
0.27
Carbon-14
7
1 x 10
270
Cesium-137
1 x 104
0.27
Cobalt-60
1 x 105
2.7
Nickel-63
1 x 108
2700
Americium-241
1 x 10
5
2.7
Phosphorus-33
8
1 x 10
2700
Sulphur-35
1 x 108
2700
Tritium (H-3)
1 x 109
27000
Phosphorus-32
1 x 10
Exemption quantities for other radionuclides may be obtained from the Radiation Safety Officer
* Based on SCHEDULE I of the Nuclear Substances & Devices Regulations which is available online (most
current): http://laws.justice.gc.ca/eng/regulations/SOR-2000-207/index.html
3.6. Purchasing Radioactive Materials
The Canadian Nuclear Safety Commission (CNSC) requires that the University maintain a record of all
radioactive materials received under the Consolidated Licence. This information is reported to the
CNSC annually and must be available for inspection by the CNSC on demand. Therefore acquisition
protocols for radioactive materials have been developed and must be strictly observed:
3.6.1.
Procedures for Ordering Radioactive Materials
Orders can only be placed by permit holders or authorized staff to the Radiation Safety Officer.
The Radiation Safety Officer will place the order with the company and charge back the researcher's
cost centre. All orders must go through the Radiation Safety Officer.
The Radiation Safety Officer must also approve any acquisitions (gifts, free samples, donations, loans,
external transfers, exchanges, etc.) of radioactive materials, including sealed sources in devices,
before shipment/transfer to the university. The following information will be required for the approval:







permit Holder Name and permit number
radionuclide
activity per unit
number of units
supplier
date expected
delivery location (Building and room number)
Any acquisitions which do not meet the criteria for approval will have to be corrected by the person
reporting the acquisition. Failure to provide the necessary information will delay the approval. Any
radioactive material arriving at the University for which there is no prior approval may be confiscated.
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3.7.Transfer of Radioactive Materials
3.7.1. Transfers within the University
a) Permit Holders are not permitted to “lend” or “borrow” unsealed radioactive materials
between laboratories of other Permit Holders without prior approval from the Radiation Safety
Officer. The Radiation Safety Officer must ensure that the “Borrower” is authorized to use the
radioisotope and the quantity that is being requested.
b) Record the quantity, the name of the person “borrowing” and their Permit Number on
Inventory Record Form.
c) The “borrower” must complete the new Inventory Record Form for their use and disposal of the
“borrowed” nuclear substance. All inventory records must be retained and be available upon
request.
3.7.2.
Transfers from Outside Institutions
a) No radioactive materials may be transferred to or from another institution or person outside the
University, without prior written notice and approval from the Radiation Safety Officer.
b) The receiving institution will require a valid CNSC licence. In addition, the materials must be
properly packaged and documented according to CNSC and Transport Canada Regulations.
c) Other institutions such as teaching hospitals will have their own separate CNSC licence.
Radioactive materials intended for use within the University must be purchased under the
University licence and material for use within another outside institution must be purchased
under the other institution’s CNSC licence.
Any person who is in possession of radioactive material which is not covered by a valid Permit may
have the material confiscated and face disciplinary action.
3.8. Receipt of Radioactive Packages
Only persons trained and having a valid TDG Class 7 training certificate may receive radioactive
packages. The following procedures should be used upon receipt of any radioactive material:
a) Shipments must be inspected immediately upon arrival using the guidance of CNSC poster
INFO-0744 “Guidelines for Handling Packages Containing Nuclear Substances”.
b) Wear a laboratory coat and gloves when inspecting the package.
c) Verify the radioisotope, the activity and other details with information on the packaging slip
and purchase order, transport labels. Where applicable, monitor the radiation field about the
package and compare with units stated on the package.
d) Swipe test the packaging for removable surface contamination. Contamination may occur
due to defective containers which have not been properly checked upon arrival. If
contamination is suspected, open the package only in a fume hood. If no contamination is
found on the outer packaging material, the warning labels must be removed or defaced to
remove any reference to radioactive materials prior to disposing in the non radioactive regular
waste.
e) Report any anomalies (leakage, contamination, incorrect shipment) to the shipper.
f) Store the radioactive material according to the requirements of the manufacturer in a secure
area.
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g) Remove gloves and wash hands after handling the material and check hands and clothing for
contamination and wash hands following these procedures.
h) Log the appropriate information in the package receipt form.
i) Prepare a new inventory sheet(s) for the radioactive material(s) received.
3.9. Inventory Control
CNSC Regulations require that an inventory of all radioactive materials in possession under the terms
of the Nuclear Substances and Radiation Devices Licences be maintained.
a) A Radiation Permit Holder will maintain an accurate, current inventory of all radioactive
material in his/her possession. Blank Inventory Forms can be downloaded from:
http://www.ryerson.ca/irm/programs_policies/radiation.html under Laboratory Forms for
unsealed radioactive materials that can be used to ensure updated and complete laboratory
inventory. For each stock vial, the inventory record must be completed after each use
including amount used each time and person using radioactive materials, as well as the final
date of disposal.
b) The inventory records must be kept up to date and available for inspection by the Radiation
Safety Officer or the Canadian Nuclear Safety Commission.
c) All radioisotope inventory records must be maintained for three years following disposal of the
material. If a Permit Holder leaves the University, these records should be transferred to
Integrated Risk Management.
3.10. Storage
A radionuclide storage area or container is defined as that area within a licensed facility that provides
appropriate shielding, ventilation and security for the materials. The area may be a lead or Plexiglas
box, refrigerator, cupboard, or fume hood.
For security and safety reasons, it is important that access control to areas storing radioactive
materials be strictly observed. Radioactive material shall be kept or stored in a manner that:
a) Access to radioactive materials is restricted to only those persons authorized by the Ryerson
Radiation Permit.
b) All radionuclides (stock, aliquots, products, wastes) must be stored in approved containers
within approved areas/laboratories. All radioactive chemicals must be kept in storage
cabinets, refrigerators or freezers that have been designated for this purpose. Radio-labelled
biological materials or other radioactive compounds that must be stored below -15 0C may be
kept in freezers in departmental laboratories as long as they are adequately protected against
accidental breakage and unauthorized access.
c) All cabinets, refrigerators or freezers used for the storage must be clearly marked with a
radiation warning sign on the outside. If only a section of a cupboard or freezer is used, the
inside area must be clearly marked. The storage container is labelled in accordance with
requirements outlined in section 3.5. All approved containers must be labelled with the date,
activity, and name of radionuclide.
d) When the area is unattended, all radioactive materials must be stored in a locked location to
prevent access.
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e) Radioactive materials must be properly shielded and stored such that dose rates are less than
2.5 µSv/h at all normally occupied areas outside of the storage area. Many radioisotopes have
high energy beta and gamma energies which can create a potential external radiation
hazard and must be kept in suitably shielded containers. For example, P-32 which emits high
energy beta radiation should also be kept in containers with sufficiently thick Plexiglas
shielding.
f) Provides adequate protection against theft, fire, explosion, flooding or accidental breakage of
primary storage containers.
g) Radioactive waste must not be stored under the work area without adequate shielding and
containment, as this may present a radiation exposure to personnel working in this area.
3.11. Waste Disposal
The Canadian Nuclear Safety Commission is informed of all disposals of radioactive materials from the
University. Contact the Radiation Safety Officer for the disposal of all radioactive materials and
devices.
3.11.1. General
a) Radioactive waste must be kept secured while in the laboratory awaiting disposal.
b) Record the quantity and method of disposal, date of disposal and the user name on the
Radioisotope Inventory Control Form:
http://www.ryerson.ca/irm/programs_policies/radiation.html under laboratory Forms. The Form
must be completed and kept current at all times and must be signed and dated when
disposal is complete.
c) Waste materials must be adequately shielded or stored in a location to minimize potential
exposure.
d) Each waste container must have a completed Radioactive Waste Tag. Waste tags will be
provided by external radioactive waste disposal contractor. Information (waste type, date,
isotope and radioactivity) must be legibly and accurately recorded.
e) Radioactive waste must not contain any viable biohazardous agents.
f) Radioactive waste container must not show any evidence of leaking and must be checked
for non-fixed contamination on surfaces (mainly outside) using a wipe test procedure.
There are several different types of radioactive waste streams that may require specialized
radioactive waste disposal. The procedures for several waste streams are outlined below.
3.11.2. Specific Radioactive Waste Streams
RADIOACTIVE DEVICES (SEALED SOURCES)
•
In equipment containing sealed sources (e.g., gas chromatographs, etc.) the sealed source must
be removed and equipment decommissioned prior to disposal. Contact the Radiation Safety
Officer prior to disposal of radiation devices to arrange for removal of source(s) and
decommissioning. See Section 3.16 on Sealed Sources.
SOLID RADIOACTIVE WASTE
•
All solid radioactive waste must be collected in assigned radioactive waste container.
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•
•
•
Waste containers must be monitored and shielded if required.
Non-contaminated materials must not be discarded with radioactive waste.
Solid waste that does not contain any other hazardous materials and is less than the disposal limits
outlined in Table 7 can be disposed of as regular waste.
RADIOACTIVE SHARPS (needles and syringes)
•
•
All sharps used for dispensing radioactive materials must be placed in an approved sharps
container with a Radioactive Waste Tag attached.
The outside of sharps containers must be free of any contamination before submitting for disposal.
RADIOACTIVE STOCK SHIPMENT VIALS
•
•
All stock vials must be collected and submitted for disposal as solid radioactive waste.
All vials with some residual activity must affix label, indicating the date and the amount of activity
remaining in the vial.
LIQUID SCINTILLATION VIALS
•
•
Liquid scintillation vials must be collected separately in the laboratory. Vial caps must be securely
fastened prior to placing them into waste disposal container.
Environmentally safe biodegradable scintillation fluid is highly recommended for wipe test and
experimental procedures whenever possible.
LIQUID RADIOACTIVE WASTE
•
•
•
No liquid containing radioactive materials shall be discharged to the laboratory drains.
Following addition of liquid waste to the waste container, the radioactive waste tag must be
fully completed.
The outside of containers must be free of any contamination before submitting for disposal.
3.11.3. Aqueous Washes
a) Aqueous liquid wastes (e.g. wash water used to wash lightly contaminated glassware or
equipment) resulting from experiments with radioactive materials often contains insignificant
amounts of activity, defined by the Canadian Nuclear Safety Commission (CNSC) as nonradioactive. If the quantity of radioactivity is below the release criteria outlined in Table 7 , the
CNSC considers the hazard to be non-radioactive and insignificant. However, attention must
be paid whether there still exists a biological or chemical hazard in terms of disposal.
b) The Permit Holder must obtain authorization from the Radiation Safety Officer prior to any
release into the sewer system. The CNSC prescribes release limits on an annual basis per
building. The Radiation Safety Officer will track the annual per building release to ensure that
the annual limit is not exceeded.
c) Any aqueous liquid waste authorized for release may be disposed to the regular drain,
followed by several litres of running water to ensure that the sink trap is flushed completely.
d) Any non-aqueous liquid waste (e.g. organic solvent) meeting the criteria in Table 7 should be
disposed as chemical waste.
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e) Activities discovered in any liquid waste above the levels in Table 7 must be disposed to the
liquid waste container, completing the waste tag, identifying the contents.
Table 7. Radioactive Waste Disposal Criteria for Individual Radioisotopes
CNSC DISPOSAL LIMITS*
Aqueous Liquid Waste For Sewer
Release Per Building
Solid Waste
Radionuclide
MBq /kg
µCi/kg
MBq/ yr
mCi/yr
Carbon 14
3.7
100
10,000
270
Hydrogen 3
37
1000
1,000,000
2700
Phosphorus 32
0.37
10
1
0.027
Phosphorus 33
1
27
10
0.27
Sulphur 35
0.37
10
1000
27
For other radionuclides, please contact the Radiation Safety Officer
* Based on CNSC C-222 Release Criteria & Licence conditions
f)
Alternatively, the release of short-lived radioactive materials may be delayed until such time
that the material has decayed to meet the release criteria outlined in Table 7. This process is
termed delay and decay. Consult the Radiation Safety Officer for storage criteria per
container. Authorization is still required from the Radiation Safety Officer prior to any release.
3.12. Radiation Detection Equipment
Radiation detection equipment in a radiation safety program is used to perform surveys for either
contamination or for dose rates. Not all meters are suitable or sensitive enough to detect all types of
radiation.
3.12.1. Choice of Instrument
Detection equipment must be chosen to have sufficient sensitivity for the radioisotope being
monitored. The Permit Holder must determine the radioisotope(s) and thus the type of radiation that
will be monitored (beta, gamma, alpha, X-ray or a mixture) and anticipated levels. Special
consideration must be given for such parameters as minimum detection limits, efficiency for
radioisotope in question, ease of use, etc.
Portable instruments are available for contamination and dose rate survey monitoring. The most
commonly used dose rate survey meter has an ion chamber detector. However, another popular
detector, the Geiger Mueller (GM) counter, can measure radiation levels at lower levels and is less
expensive than a survey meter with an ion chamber detector. GM detectors are also frequently used
as contamination meters for beta emitting radionuclides with enough energy to penetrate though the
detector window. Such GM detectors are often referred to as “pancake” detectors because of their
shape. Solid inorganic scintillator crystal detectors, such as thallium-doped sodium iodide (NaI(Tl)) are
used for the detection of gamma emitting radionuclides. The thickness of the crystal will depend on
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the energy range of the gammas to be detected. Thicker crystals are used for high energy gamma
detectors, while thinner crystals are used for low energy gamma detectors.
Non-portable instruments used for counting wipes, such as liquid scintillation counters are also used for
contamination monitoring. Because of the direct contact between the radionuclide on the wipe
surface and the organic liquid scintillation “cocktail”, these instruments offer higher detection
efficiency and are the only approved method for tritium (H-3) detection.
Whatever your purpose, instrument selection must be approved by the Radiation Safety Officer.
3.12.2. Efficiency
Efficiencies for all radiation detection equipment must be obtained for those radionuclides that will be
used in the laboratory. Portable contamination survey meters must be checked for efficiency
annually.
Besides electronics, shape and size of detector, many other factors can affect overall efficiency of
your instrument. The most important factor, which is also in the control of the user, is distance from
source.
3.12.3. Annual Calibration
It is a requirement of the CNSC to have a dose rate survey meter calibrated annually. Additionally, it
is also a University requirement to have contamination monitoring equipment calibrated annually as
well. For calibration of equipment, please contact the Radiation Safety Officer.
3.12.4. Registration
Radiation detection equipment must be registered with the Radiation Safety Officer.
3.12.5. Maintenance
Radiation detection equipment should be routinely serviced according to the manufacturer's
instructions. Keep a record of the service information and dates. Refer to Contamination Monitoring
Procedures: http://www.ryerson.ca/irm/programs_policies/radiation.html under Standard Operating
Procedures for further information.
3.13. Radiation Surveys for External Radiation and Contamination
3.13.1. Dose Rate Surveys
It is a requirement for researchers working with high energy beta emitters such as Phosphorus-32 (P-32)
and gamma emitters such as Cr-51, I-125, etc., to be able to determine dose rates. Survey meters will
be required to survey incoming packages and monitor levels in the vicinity of active work and storage
areas. The radiation levels in radioisotope laboratories (workspace) should be less than 2.5 µSv/h (<
0.25 mR/h). Appropriate shielding should be applied to the radioactive source to reduce the dose
rates to below the aforementioned level.
Entrances to areas where the effective dose rate is greater than 25 µSv/h (> 2.5 mR/h) in the
room/area must be marked with a sign that has a radiation warning symbol and the words
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“Rayonnement- Danger - Radiation”. Signs can be obtained from the Radiation Safety Officer. Refer
to Section 3.5 Posting of Required Laboratory Signs for further details.
Following completion of a dose rate survey, record results of levels and locations monitored. Keep the
results of the monitoring in a log book, stored in a location accessible for inspection.
3.13.2. Detection of Surface Contamination
All radioisotope facilities must be monitored for contamination. Monitoring and contamination control
checks must be carried out routinely, and at a minimum within seven days of the usage of
radioisotopes. Contaminated areas must be cleaned without delay and verified by further
contamination control checks.
There are several elements to a monitoring program for surface contamination including frequency,
location, decontamination procedures and record keeping. Refer to Contamination Monitoring
procedures: http://www.ryerson.ca/irm/programs_policies/radiation.html under Standard Operating
Procedures for more specific details.
3.13.2.1.
Calculating Amount of Contamination
Contamination criteria established by the CNSC for commonly used radioisotopes are outlined below
for some common radionuclides. Table 8 identifies the Action Limits in controlled areas (i.e. areas
where radioactive materials are normally used or stored) for levels of contamination levels. Those
levels which exceed the Action Limits will require decontamination. The limits for other areas (other
areas in the lab outside of radiation work zone and public spaces) are ten times lower (i.e., 0.3, 3, and
30). The Permit Holder must report contamination in excess of the Action Limits to the Radiation Safety
Officer. The RSO will conduct an investigation to establish the cause for reaching this action level,
identify, and take action to help prevent such contamination situations and potential for exposures.
Table 8. Action Levels for Removable Surface Contamination in Controlled Areas for Selected Radioactive
materials
CNSC Contamination
Limit for controlled areas
2
Contamination
Action Level
Radionuclide
(Bq/cm )
(Bq/cm2)
Carbon-14
300
150
Chromium-51
300
150
Iodine-125
300
150
Iodine-131
30
15
Phosphorus-32
300
150
Phosphorus-33
300
150
Sodium-22
3
1.5
Sulphur-35
300
150
Tritium (H-3)
300
150
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For other radioactive materials, please contact the Radiation Safety Officer
Removable Contamination
The readings from radiation detection instruments can be related to regulatory criteria if the efficiency
of the instrument for a specific radioisotope is known. For mixtures of radionuclides, do all the
calculations using the radioisotope for which the instrument has the lowest detection efficiency.
NOTE: Calculation below is only valid if the removable activity is greater than the
instrument’s MDA (Minimum Detectable Activity) for that radionuclide.
Removable Activity (Bq/cm2) =
Where:
(𝑵−𝑵𝒃 )
𝑬×𝟔𝟎×𝑨×𝑭
N = is the total count rate in counts per minute (CPM) measured directly or on the wipe.
Nb = is the count rate of the blank (in CPM)
E = instrument efficiency for specific isotope (e.g. for 26% efficiency, E = 0.26)
60 = sec/min (because values entered in CPM)
A = area in cm2 (for swipes, wipe an area of 100 cm2, for direct measurements use detector area)
F = is the collection factor for the wipe. Use a value of F = 0.1 (i.e., 10%). Do not use for direct
measurement (or use a value of 1, i.e. 100%).
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SAMPLE CALCULATION
2
A tritium contamination occurred on a laboratory bench. A wipe of 100 cm was taken and counted in
the liquid scintillation counter for 1 minute with a result of 750 cpm for the sample and 40 cpm for the
2
blank. Determine the result of the measurement of the sample in Bq/cm
Assumptions: wipe efficiency is 10% and detector efficiency for tritium is 55%
SOLUTION:
LLD =
3 + 4.65 * Background × Counting Time
Counting Time
LLD = 3+(4.65*√40)= 32.4 cpm
Net counts = 750- 40 = 710 > LLD, therefore:
Removable Activity =
(𝑵−𝑵𝒃 )
𝑬×𝟔𝟎×𝑨×𝑭
=
(𝟕𝟓𝟎−𝟒𝟎)
𝟎.𝟓𝟓×𝟔𝟎×𝟏𝟎𝟎×𝟎.𝟏
= 2.15 Bq/cm2
2
Comparing to Table 8 action levels in a controlled area for tritium of 150 Bq/cm , the sample is not
contaminated and no further action is required.
When the removable activity has been calculated, the figure should be compared to the
contamination action levels outlined in Table 8. If the limits have been exceeded, then the next step
of decontamination is required (refer to Table 9 for decontamination methods).
Fixed (Non removable) Contamination
Fixed contamination on a surface can only be assessed using the direct method. That is, calculation
without the correction for the efficiency of the wipe (no F value or use F = 1) and using the detector’s
area instead of the 100 cm2 for wipes. The dose rate due to fixed contamination should not exceed
2.5 µSv/h at 30 cm from the surface. If so, the area must be shielded with appropriate shielding
material to bring the dose rate below 2.5 µSv/h at 30 cm.
3.13.2.2.
Decontamination Procedures for Areas and Equipment
Should contamination in a work area or on equipment be discovered through routine monitoring,
decontamination methods to clean surfaces are outlined in Table 9. The following decontamination
procedures are to be followed:
a) If contamination is detected on the floor, it must be cleaned immediately.
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b) If contamination is detected on the bench covering, remove it to solid radioactive waste
container and monitor the surface underneath. If contamination is still present, clean the
surface.
c) If using a portable contamination meter and contamination is noted in the active work area, it
may be due to radiation sources and not due to contamination. If it is not feasible to remove
the sources, then wipes must be taken (i.e., indirect measurements).
d) Clean all areas where contamination is detected until no contamination is detectable or
further cleaning does not reduce the contamination (i.e., fixed contamination).
e) Radioisotope work areas in the vicinity where maintenance work is to be carried out must be
decontaminated prior to the start of such work.
Table 9. Decontamination Methods for Removable Surface Contamination
Contaminated Surface
Dry, porous surface
Method
HEPA vacuum
Spills (small)
Hot water and detergent
Instructions
•
Avoid water reactions
•
All dust must be filtered out using only HEPA filters
•
Vacuum is considered contaminated
•
Blot up liquid and rinse with hot water & detergent
•
May be used on glassware and clothing
•
Highly effective if immediately applied to non porous
surface
•
Not for large areas of decon
•
Not effective for areas of long term contamination
•
make a solution of 3% complexing agent with water
•
spray surface with solution
•
keep moist for 30 minutes
•
remove solution and rinse
•
smaller objects can be immersed in solution
•
can be dissolved by immersion or applying solvent to the
surface, blotting up the liquid and wiping clean
•
good ventilation required for flammable toxic vapours
•
Immerse smaller objects or brush on in a 1-2 N acid
solution then flush with water
•
material must be scrubbed with detergent water mixture
and rinsed
•
Acids may cause excessive corrosion and are
hazardous to skin and eyes
•
Apply abrasive to surface, rub & rinse with water
Non porous
Non porous surface
Organic material
Metal and porous surface
Non porous surface
Decon 75 or Alconox
Organic solvent
Inorganic acid
Abrasion (Steel wool)
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Non Removable (Fixed) Contamination
Monitoring is required after decontamination attempts, to ensure the levels are below the
contamination action levels set out in Table 8. If contamination cannot be removed, the
contaminated area can be covered, marked with radiation warning tape and shielded if required.
The level of fixed contamination (i.e. the amount of contamination remaining in Bq/cm2) should be
determined and posted and noted in the Contamination Monitoring Form.
3.14. Record Keeping Requirements
All records maintained by the Radiation Safety Officer in the Integrated Risk Management offices will
be kept in compliance with CNSC regulations. Records, in respect of any radioactive materials in the
Permit Holder’s possession, shall be kept of the following:
3.14.1. Inventory Records
Inventory records must be kept. One Radioisotope Inventory Control Form for Unsealed Radioactive
materials is required for each vial. The form is available for download at:
http://www.ryerson.ca/irm/programs_policies/radiation.html under Laboratory Forms. Copies of the
purchase order (if available), packing slips and any Transportation of Dangerous Goods documents
must be attached to the form.
3.14.2. Contamination Monitoring
Contamination monitoring must be done at least weekly when isotopes are being used. Following
completion of a contamination survey, all results must be recorded in the log book containing the
Radioisotope Contamination Monitoring Form:
http://www.ryerson.ca/irm/programs_policies/radiation.html under Standard Operating Procedures.
During those periods when there is no isotope use, this inactivity must be indicated on the forms. Keep
the results of the monitoring in a log book, stored in a location accessible for inspection. The
Contamination Monitoring Forms are to be completed and available at all times for inspection by the
RSO and CNSC. Printouts from scintillation/gamma counters must be attached to the Radioisotope
Contamination Monitoring Form. Records of all contamination measurements shall be maintained
and available for inspection.
3.14.3. Waste Records
Waste logs must be kept to detail all wastes disposed. The Radioisotope Inventory Control Form can
also be used to track waste disposal.
3.14.4. Training Records
A list of authorized users, working under the permit that use or handle radioactive materials must be
available and kept up to date. Maintain records of the training received by a worker for 3 years after
termination of the worker’s employment at which point permission to dispose of records must be
obtained by the CNSC.
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3.14.5. Inspection Records
Record of every inspection, measurement, and test or servicing in accordance with permit conditions.
Records must be kept for 3 years after the expiry date of the last permit that was issued to the Permit
Holder at which point permission to dispose of records must be obtained by the CNSC.
3.14.6. Sealed Source records
Record the model, serial number of a sealed source and device containing a radioactive source. Also
keep copies of any manuals that accompanied the source or device. If feasible, another copy of the
manual should be sent to the Radiation Safety Officer.
3.14.7. Calibration Records
All annual calibration records for radiation detection equipment must be kept for three years after the
expiry of the permit. Permission to dispose of records must be obtained by the CNSC.
Note: Approval from the CNSC is required before disposing of any records. Please
contact the Radiation Safety Officer if you wish to dispose of records that are more
than 3 years old.
3.15. Work Practices for Specific Radionuclides
The Canadian Nuclear Safety Commission has issued Radiation Safety Data Sheets for several
isotopes, including H-3, P-32, S-35, I-125, I-131 and others. The Radiation Data Sheets may be found at
the CNSC website:
http://www.nuclearsafety.gc.ca/eng/resources/radiation/radiation-safety-data-sheets/index.cfm
The Data Sheets refer to monitoring, emergency procedures and some radiological physical
properties. In addition to the CNSC Radiation Safety Data Sheets, listed below are additional work
practices for beta and gamma emitters.
3.15.1. Low Energy Beta Emitters
Low energy beta radiation, such as tritium (H-3) is blocked readily by the dead layer of skin cells. Thus
it poses no radiation hazard unless it is ingested and enters the body where it can exert its effects on
cells at very short distances. It is important to take precautions to prevent ingestion or inhalation.
•
•
•
Exposure Monitoring: Dosimeter badges are not needed or required
Contamination Monitoring: Wipe tests in Liquid Scintillation Counter
Shielding: Not required
Specific concerns with individual radioisotopes include:
TRITIUM (H-3) - Radiolytic breakdown of labelled compounds is common. The consequent release of
either tritium gas or tritiated water vapour can pose a hazard in poorly ventilated areas. Tritiated
borohydride is quite unstable and must always be opened and handled inside a fume hood.
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CARBON-14 - Most compounds are quite stable and need only to be protected from bacterial
breakdown. The common exceptions are bicarbonate and carbonate compounds. These
compounds must be stored in a well ventilated area and must always be opened and handled inside
a fume hood.
SULPHUR-35 - All compounds in common use are stable and need only be protected from bacterial
breakdown. When labelling cells in culture with S-35 methionine, S-35 contaminated gases are often
produced. Therefore, the culture should be placed in a plastic bag with activated charcoal and the
incubator monitored for contamination.
CALCIUM-45 - All compounds in common use are very stable. Cleaning of contaminated surfaces is
difficult and is best accomplished with mild acid (acetic) and chelators.
3.15.2. High Energy Beta Emitters
High energy beta radiation emitters such as P-32 penetrate skin readily. As well, the high velocity
electrons displace orbital electrons from molecules and cause the emission of low-energy X-rays
called bremsstrahlung. This displacement effect is more efficient in dense materials. Thus it is necessary
to shield high energy beta radiation with low density shielding such as plastic. Substantial irradiation of
the hands can occur when moderate activities of these radioisotopes are handled. Due to the
potentially high dose rates encountered, work should never be carried out above an open container
of a high energy beta emitter. Good work habits are essential to prevent accidental ingestion.
•
•
•
Exposure Monitoring: Whole body dosimeter badges must be worn
Contamination Monitoring: GM pancake
Shielding: Plexiglas
PHOSPOHROUS-32 - It is mandatory to wear ring dosimeters if more than 50 MBq (1.35 mCi) of
Phosphorus-32 is handled.
3.15.3. Gamma Emitters
•
•
•
Exposure Monitoring: Whole body dosimeter badges must be worn
Contamination Monitoring: Sodium Iodide detector
Shielding: Lead
RADIOACTIVE IODINE (IODINE 125 and IODINE 131)
It is very important to prevent ingestion or inhalation of radioactive iodine. Iodine vaporizes readily
and can be inhaled when it is in the I2 state. All reactions which are employed to label organic
molecules with radioactive iodine require the iodine to be in the volatile I2 state. Great care must be
taken to prevent the escape of radioactive iodine vapours during these reactions. It is mandatory
that:
i.
ii.
all reactions be carried out in an approved fume hood
double gloves must be worn and the outer pair must be discarded between steps
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The toxicity of Iodine-125 is compensated by its very low energy gamma radiation. Thus the external
radiation hazard from Iodine-125 is easily eliminated by only 1 mm of lead (for quantities typically used
in university research labs). However, it remains an internal hazard, concentrating in the thyroid gland.
Accidental ingestion can be prevented by good work habits and by frequent checks for surface
contamination. A Geiger-Muller detector will detect Iodine-131 (because of the medium energy beta)
but Iodine-125 can only be detected with a thin crystal sodium-iodide detector. Wipe tests are the
easiest way to detect whether surfaces are contaminated with radio-Iodine.
3.16. Sealed Sources
Sealed sources are radioactive materials where the radioisotope is encapsulated to prevent direct
manipulation of the material. They are usually small sources used for instrument calibration. However,
sealed sources also include any radioactive material incorporated into a device such as a liquid
scintillation counter, gas chromatograph or other such unit. Sealed sources may also exist in an
irradiator, but special permission is required to possess such units.
An inventory of all sealed sources held under an internal permit is listed on the permit itself. This will
constitute the inventory record provided that it is accurate. It is the responsibility of the permit holder
to ensure that the record of sealed sources on the permit is accurate. Sealed sources and devices
containing sealed sources must be durably and clearly labelled with a radiation warning sign
indicating the type and quantity of radioactive material present.
A permit holder is required to notify the Radiation Safety Officer prior to the receipt of any sealed
source or device containing a sealed source. Information on the radionuclide, its activity and the
device in which it is located must be submitted in writing. The RSO will arrange for the permit
amendment. A permit holder must also notify the Radiation Safety Officer prior to the disposal or
transfer of any sealed source or a device containing a sealed source.
Information on the device and its intended disposition must be submitted to the RSO. In the case of
disposal, the RSO will make the appropriate arrangements for removal of the source and the revision
of the permit. In the case of a transfer, the RSO will arrange for the permit revision and the leak testing
of the source.
3.16.1. Leak testing for sealed sources of 50 MBq (1.35 mCi) or more
Leak testing of sealed sources is required under CNSC regulations to ensure that a sealed source has
not developed defects, has been damaged or has degraded so as to present an unrecognized
radiological risk to persons using or working near the source.
Such sources must be leak tested according to the following:
Source Type/Condition
Frequency of Leak testing
Sealed source in storage
Sealed source inside an instrument
"Free" sealed source
24 months (2 years)
12 months (1 year)
6 months
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The leak testing procedures must meet certain strict criteria and thus be performed under a CNSC
approved protocol. Please contact the Radiation Safety Officer who will arrange for leak testing to be
performed by a company that has a CNSC approved protocol.
3.17. Decommissioning Rooms
The Permit Holder shall ensure that all areas/laboratories identified on the permit are decommissioned
upon termination of the Permit.
Decommissioning would include:
a)
b)
c)
d)
e)
f)
g)
Removal of all radioactive materials or devices to an approved site.
Appropriate disposal of all radioactive waste.
Removal of all radioactive warning signs and labels.
Monitor all areas and decontaminate to meet the CNSC limits (Table 10).
Complete Decommissioning Report and forward to Radiation Safety Officer.
Update all records.
Records must be retained for the period ending 3 years after the expiry date of the last Internal
Permit issued. Refer to Section 3.14 – Record Keeping Requirements – for more details.
For supervised public areas and for decommissioning, removable surface contamination (i.e., non
fixed contamination) limit criteria averaged over an area not exceeding 100 cm2 are outlined in Table
10:
Table 10. Classification of Selected Radioactive materials for Removable Surface Contamination Levels in
Decommissioned or Public Areas
Nuclear Substance
CNSC Contamination
Limit for Public Area
(Bq/cm2)
Carbon-14
30
Chlorine-36
30
Calcium-45
30
Chromium-51
30
Sodium-22
0.3
Sulphur-35
30
Tritium (H-3)
30
Phosphorus-32
30
Phosphorus-33
30
Iodine-125
30
Iodine-131
3
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In the case of abandoned facilities, the Radiation Safety Officer will immediately arrange for the
decommissioning of the facilities and the disposal of all radioactive material in those facilities. If
significant costs are involved in this procedure, all costs will be charged to the department with the
abandoned facility. A facility may be declared to be abandoned when the Permit Holder is no
longer at a Ryerson University facility on a regular basis, takes a sabbatical or leave and has not
notified the Radiation Safety Officer of any alternative arrangements, or is no longer in the employ of
Ryerson University.
3.18. Ryerson Radiation Permit Revisions
3.18.1. Amendments
Permit modifications, additions and/or deletions may be performed at any time via the on-line permit
system. The Radiation Safety Officer will be responsible for approving all permit requests. Note that
increases in possession limits may change the laboratory designation level to the next level of
containment (e.g. from basic to intermediate). Depending on the isotope, this may require additional
precautions to be taken or even changes in the design of the laboratory. Any designation above
basic containment level also requires approval from the CNSC. The new/updated permit will not be
approved until all requirements have been met.
3.18.2. Renewals
A permit renewal notice is automatically sent from the permit system at one month prior to the official
expiry date, and reminders are also sent subsequently every week until expiry. A permit may also be
cancelled at the time of permit renewal. It is recommended, if the permit holder is not currently using
radioisotopes and has no immediate plans to resume such work, that the permit be cancelled. If the
work with radioisotopes resumes, the permit may be reactivated.
3.18.3. Sabbatical/Extended Leave
A permit is granted on the grounds that the permit holder is aware and responsible for the activities in
the radioisotope facilities. If a Permit Holder is taking a sabbatical or other type of leave where he or
she will not be able to administer this responsibility, arrangements must be made prior to taking the
leave. Permit Holders leaving for an extended period of time (sabbatical or longer than a 4 week
period) shall advise the Radiation Safety Officer in writing, prior to leaving. The Permit Holder must
arrange for another Permit Holder to assume the permit responsibilities during his/her absence. The
Radiation Safety Officer will confirm acceptance with the newly appointed Permit Holder and his/her
Departmental Chair. If no permit holder can be found, the Permit may be reclassified as an Inactive
Permit.
A temporary interruption of the permit may be arranged or the responsibility for the work may be
assumed by another current permit holder. The latter arrangement must be confirmed in writing by
both parties stipulating the effective time period. Any permit holder acting on behalf of another
permit holder is responsible for all activities under both permits and subject to all policies. If a permit
holder does not advise the Radiation Safety Officer prior to taking leave, the facilities may be
considered to be abandoned.
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3.18.4. Inactive Status
Occasionally when the research with radioactive materials stops for longer periods of time (1 year or
longer) the Internal Permit may be designated as “inactive” within the permit’s validity period. No
inventory (stocks, aliquots, or waste) or waste shall be on hand. The laboratories that were used for
radioactive work must be decommissioned by the Permit Holder. The Permit Holder may contact the
Radiation Safety Officer at any time to re-activate the Permit if it has not expired (within validity
period).
3.18.5. Suspension/Revocation
A permit suspension or revocation may result when the CNSC Regulations or permit conditions are
violated. Suspension or revocation of permits will be at the discretion of the Vice President
Administration & Finance under the Enforcement Policy for Radiation Safety (in Appendix A). The
Radiation Safety Officer will make all necessary arrangements including the decommissioning of any
facilities no longer required for radioisotope work.
3.18.6. Expiry/Termination
The Permit Holder must request termination of the Permit when his/her employment is terminated or
when there are no further plans to continue with radioactive work. Notice must be given at least 4
weeks prior to leaving the University to ensure that the laboratories are decommissioned and all the
records are released to the Radiation Safety Officer. Records must be kept 3 years past employment/
termination/expiry of the Permit (refer to Section 3.14). The Department Chair will be held responsible
in the absence of the Permit Holder.
A permit may also be terminated at the time of permit renewal. It is recommended, if the Permit
Holder is not currently using radioisotopes and has no immediate plans to resume such work, that the
permit be terminated. If the work with radioisotopes resumes, the permit may be reactivated.
3.19. Self-Audit Checklist – Top 10 Things to Remember
1. No food or drink is consumed in the lab and there is no evidence of food consumption such as
wrappers, cups and utensils.
2. Valid Ryerson Radiation Permit is posted in each laboratory listed on the permit.
3. Work is conducted according to Permit conditions and only in the locations listed on the
Permit.
4. All personnel working with radioactive materials have successfully received training.
5. Personnel wear the appropriate dosimetry, if applicable.
6. All radioactive sources and containers of radioactive material are labelled with the Isotope,
Activity, and the Reference Date.
7. Contamination monitoring is performed at least weekly, and records are maintained.
8. An accurate inventory of all radioactive material within the lab is maintained.
9. Radioactive waste containers are used appropriately.
10. Security of unsealed radioactive materials being maintained.
For more information, please contact the Radiation Safety Officer.
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4. SECURITY
It is required by the Canadian Nuclear Safety Commission (CNSC) that security of radioactive
materials must be in place at all times. It is the permit holder’s responsibility to ensure that all
radioactive material is kept secure at all times. The level of assessed risk determines the security
measures required to protect the radioactive material. The risk is based on the type of isotope, the
amount of activity, location, the type of storage and proposed use. Securing access from
unauthorized persons such as untrained persons will also prevent accidental exposure.
4.1. Authorized Access
a) Only Authorized Users and the Radiation Safety Officer may have access to radioactive
materials and all radioactive materials must be secured at all times from unauthorized
personnel.
b) Persons unknown to the occupants of an area where radioactive materials are used or stored
should not be permitted into the area without proper identification and a legitimate reason for
entry.
4.2. Maintaining Security
When an authorized user is not present in a room containing radioactive materials, that material must
be locked within a storage unit (cabinet, refrigerator or freezer, wherever applicable). Unattended
radioactive materials must be secured by locking the laboratory door when not attended. To ensure
that the security of these materials is maintained, the Radiation Safety Officer or Ryerson Security will
lock laboratory doors if the area is found to be unoccupied and radioactive materials not secured.
4.3. Bringing Radioactive materials on Campus
Only authorized users may acquire (through purchases, transfers from other institutions, loans, gifts)
radioactive materials. All acquisitions must be first approved by the Radiation Safety Officer prior to
arrival on campus. Advance notice of incoming radioactive materials, allows the Radiation Safety
Officer to determine if sufficient controls measures (such security, training, storage, dose control,
permit amendments) are in place for the incoming material.
4.4. Missing Radioactive materials
Any suspicion of missing radioactive materials such as loss or theft, misuse or suspicious activities must
be reported immediately to the Radiation Safety Officer at extension 4212. After-hours please contact
Ryerson Security at 979-5040 who will contact the Radiation Safety Officer.
5. EMERGENCY PROCEDURES
In the event of any spill of radioactive material it is important that the correct steps be taken promptly
to avoid spread of contamination and unnecessary exposure.
PREVENT ACCESS - to contaminated area by marking the area with warning signs, close the laboratory
doors, etc.
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MONITOR - all persons, shoes, clothing, etc., who may be contaminated. Perform simple
decontamination as soon as possible.
REPORT - spill to supervisor.
RECORD - after decontamination, adjust inventory/waste records.
Follow Spill Procedures outlined in CNSC INFO-0743
“SPILL PROCEDURES” which must be posted in your lab
Notification
The Radiation Safety Officer must be notified in the event of a spill involving any one or more of the
following situations:
•
•
•
•
•
When a spill is greater than a minor spill quantity as defined in Table 11
When inaccessible areas are suspected to be contaminated
When contamination of unknown origin is detected
When all reasonable efforts to decontaminate are unsuccessful in reducing the level of
contamination to regulatory limits outlined in Table 9
When contamination of personnel has occurred (refer to Table 12)
Table 11. Classification of Minor Spills for Selected Radionuclides
Radionuclide
Exemption Quantity (EQ)
Minor Spill Quantity(<100 EQ)
(MBq)
(MBq)
(mCi)
Carbon-14
10
1000
27
Phosphorus-32
0.1
10
0.27
Phosphorus-33
100
10000
270
Sulphur-35
100
10000
270
Tritium (H-3)
1000
100,000
2700
Exemption quantities for other radionuclides may be obtained from the Radiation Safety Officer.
EMERGENCY TELEPHONE NUMBERS:
Radiation Safety Officer: ext 4212
After hours: Dial 80 (Campus Security) 24 hours
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Contaminated Personnel (Skin or clothing)
Personnel working with radioactive material should understand its chemical and radioactive
properties such that a prompt response to a suspected intake of material can be carried out. If the
material is chemically toxic as well as radioactive, treat for chemical toxicity first. Prompt medical
attention is the best procedure.
Table 12. Procedures for Decontamination of Contaminated Personnel
Emergency Decontamination Steps
Contaminated clothing
• Ensure that the victim cannot be further contaminated by
radioactive material or any responding emergency personnel
• Remove any contaminated clothing, place in plastic bag, labelled
as to contents, tape shut with radioactive tape
• Immediately monitor if any skin contamination has occurred and
determine location and extent of contaminated body areas using
appropriate survey instrument
Ingestion
• Obtain medical assistance immediately
No visible open wound
(skin intact)
• Flush contaminated area with copious amounts of warm water
• Wet hands and apply mild soap or detergent, lather well with
plenty of water
• Wash gently for 2 to 3 minutes and rinse thoroughly, keeping
rinse water confined to the contaminated area as much as
possible
• Monitor decontamination using appropriate survey techniques
• Repeat wash/rinse procedure if necessary
• If further washing does not remove the contamination, contact
the RSO.
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Visible wound
(cuts, abrasions, or open
wounds
• Obtain medical assistance
• Advise emergency personnel of the radioactive material, extent
of contamination, nature of the injuries and other relevant
information
• Contact Security, requesting emergency medical assistance
(advise of the radiation hazard, the amount and chemical form of
the material, any other pertinent information)
• Provide first aid to injured personnel immediately, regardless of
contamination
• Dry clean the affected area with suction and swabs
• If skin is contaminated in the area of cuts, abrasions, or open
wounds, use wet swabs in a direction away from the area, taking
care not to spread contamination over body or into wound
• In the case of facial wounds, protect the mouth, ears, eyes and
nose from contamination
• Notify the permit holder, Radiation Safety Officer will be notified
by Security.
6. REFERENCES
6.1. Regulatory Agencies
The Canadian Nuclear Safety Commission
http://www.nuclearsafety.gc.ca/
The CNSC website contains all regulatory documents and guidelines to control radioactive materials
in Canada (these documents can also be found in the Radiation Safety Officer’s office).
International Atomic Energy Agency (IAEA)
http://www.iaea.org/
The IAEA is an international regulatory body. Transport of radioactive materials between countries is
regulated by the IAEA, as well as non proliferation of nuclear weapons.
International Commission on Radiological Protection (ICRP)
http://www.icrp.org/
This organization reviews scientific publications on the effects of ionizing radiation and publishes
recommendations, which are often incorporated into regulations by different countries all over the
world.
Health Canada’s Radiation Protection Branch
http://www.hc-sc.gc.ca/ewh-semt/radiation/measur-mesur/index-eng.php
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Health Canada’s workplace radiation website has publications on ionizing radiation and also contains
links to the National Dosimetry Services for occupational radiation monitoring.
6.2.Professional Radiation Safety Associations
Canadian Radiation Protection Association
http://crpa-acrp.org/home/
Health Physics Society (USA)
http://www.hps.org/
International Radiation Protection Association
http://www.irpa.net/
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APPENDIX A
ENFORCEMENT POLICY for RADIATION SAFETY
Introduction
The Enforcement Policy for Radiation Safety establishes a series of procedures for the internal
verification and enforcement of licensed activities authorized by the Canadian Nuclear Safety
Commission (CNSC) and University internal Radiation Permit system. The policy outlines the
mechanism for a graduated level of enforcement of the regulatory and University requirements within
the University’s radiation safety program.
Definitions
CNSC – Canadian Nuclear Safety Commission regulates the possession and use of radioactive
materials through a licensing process.
Consolidated Licence – a licence issued to Ryerson University by the Canadian Nuclear Safety
Commission for the possession and use of prescribed radioactive materials and devices
High Risk – immediate health, safety, environment or security risk
Internal Radiation Permit – issued to qualified individuals that outlines the conditions, amounts and
locations where specified radioactive materials may be used
Major Offence – a violation that poses an immediate moderate to significant risk to safety, health,
environment, security and/or places the CNSC Consolidated Licence in jeopardy. Examples include
but are not limited to:
•
•
•
•
•
•
•
•
•
•
•
food/drink in radioisotope area
contamination
inadequate monitoring
substantial dose to workers
lack of training
unauthorized possession of radioactive materials
inadequate storage
improper waste disposal
incomplete records
security breaches
multiple minor offences
Minor Offence – a breach in procedures that poses no immediate risk to safety, health, environment,
security and/or does not jeopardize the University’s CNSC Consolidated Licence. The contravention
requires corrective action. Examples include but are not limited to:
•
•
•
inadequate posting of required permits or warning signs
inappropriate use of radiation warning labels
inappropriate segregation/identification of radioactive waste
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Permit Holder – an individual who has successfully applied and received a Ryerson University Internal
Radiation Permit
LEVELS OF ENFORCEMENT
A progressive scale of enforcement has been adopted based on the level of risk and degree of
repetition of incidents. Each separate violation will be reported as a level in the progressive
enforcement policy. If corrective actions have not been completed by established timelines, the
enforcement is escalated to the next level. If multiple infractions are noted during an inspection by
the Radiation Safety Officer, then the sequence in the progressive enforcement will begin with the
most serious infraction.
Notwithstanding any of the outlined sequence of enforcement, the Radiation Safety Officer reserves
the right to bypass any level in the enforcement policy if a serious violation occurs.
Failure to comply with a policy or procedure will result in the following actions:
LEVEL A: HIGH RISK
The Radiation Safety Officer will take immediate action when there is an actual or perceived high risk
to health, safety, environment or security. The Radiation Safety Officer has the authority to temporarily
stop any work, process, or close any laboratory considered to be in violation of University procedures
or CNSC regulations. The use of radioactive materials or radiation devices at the University may be
temporarily suspended. The Faculty Dean and/or Assistant Director Risk Management & Prevention will
be informed directly of any such action.
LEVEL B: MAJOR OFFENCE
Stage 1: Radiation safety infraction is observed and recorded by the University Radiation Safety
Officer. A copy of the inspection report is forwarded to the Permit Holder and a deadline for
corrective action and reporting is specified by the Radiation Safety Officer.
Stage 2: The Permit Holder has not replied by the deadline or the same infraction is observed upon a
subsequent inspection. Correction action deadline is revised and the Faculty Dean is informed and
the notice is also copied to the Departmental Chair.
Stage 3: Radiation Safety Officer observes the same infraction in a follow up inspection. The
Radiation Safety Officer advises the Vice President Administration & Finance and the Assistant Director
Risk Management & Prevention, and the matter is pending formal sanctions. In the meantime, the
RSO may impose temporary work stoppage. Sanction options include: suspension of purchasing
privileges for radioactive materials, suspension of internal permit and confiscation of radioactive
materials by Radiation Safety Officer, or revocation of internal permit.
Appeal: Permit holders may appeal any of the sanctions imposed to the Assistant Director Risk
Management & Prevention and/or the Vice President Administration & Finance.
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LEVEL C: MINOR OFFENCE
Step 1: Upon first infraction, the Permit Holder is given a verbal warning and a deadline for
recommended corrective action by the Radiation Safety Officer.
Step 2: Upon a second same infraction, the Radiation Safety Officer issues a written notice of the
infraction to the Permit Holder. Corrective action, deadline, and the consequences of further
infractions are outlined. The Department Chair and/or Faculty Dean are notified.
Step 3: Upon the third occurrence of same infraction, the internal permit is temporarily transferred by
the Radiation Safety Officer to another qualified Permit Holder or Chair of the Department. Further
work under this permit is only allowed under the direct control of the Departmental Chair or another
senior Permit Holder. All purchase requisitions require their approval.
Step 4: Upon a fourth occurrence, the Permit Holder must show grounds as to why the internal permit
should not be revoked. A special meeting is conducted with the Permit Holder, the Radiation Safety
Officer, Chair of the Department and Faculty Dean. The RSO, Chair and Dean will make a formal
recommendation to the Assistant Director Risk Management & Prevention and Vice President
Administration & Finance who may choose to reinstate the permit.
Appeal: Permit holders may appeal any of the sanctions imposed to the Assistant Director Risk
Management & Prevention and/or the Vice President Administration & Finance.
Any violations greater than one year old will not be considered in further actions.
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