12/12-14/2006
SLAC Radiation Protection Program (RPP)
10CFR835.102 Internal Audit
Charter
General Charge:
The Audit Team is asked to:
A. Assess the RPP against the requirements of 10CFR835 as directed by
10CFR835.102 to be done once every 36 months, and
B. Evaluate the processes that are used by the Radiation Protection Department
(RP) at SLAC to manage prompt and residual radiation from accelerator
operations and radioactive material. For both of these purposes: a) determine
the adequacy of the Radiation Protection Program (RPP) and its document set
to address the radiological hazards, and b) determine quality and
comprehensiveness of records kept as required by the RPP. Areas of focus per
10CFR835 should be: RWT training, radiological instrumentation,
radiological postings, radiological surveys & monitoring, radiological
procedures, radiological hygiene, radioactive material management & sealed
source inventory control, radioactive waste management, shielding
management, and dosimetry & emergency exposure situations.
Specific evaluation questions to be asked of the RPP:
1) Is the RPP as practiced compliant with 10CFR835? If not, identify the
noncompliances and any appropriate suggestions for closing them.
2) Is the RPP document set adequate to demonstrate compliance with
10CFR835? If not, what are the program documentation gaps, and
suggestions for closing them?
3) Is the RPP efficient? If not, identify the perceived inefficiencies and
suggestions for minimizing them.
4) Based on your knowledge of practices at other DOE laboratories, is the
RPP in comportment with general ‘best laboratory practices’ and ‘best
management practices’?
5) Are there any noteworthy practices that contribute positively to the
radiological protection of the workers and the public that have merged
as positive byproducts of the RPP and its management?
6) Has SLAC planned for appropriate RPP enhancements based on the
preliminary Office of Independent Oversight findings (these findings
will be available on or about November 30 of this year)?
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Background:
Title 10 Chapter 835 Article 102 of the Code of Federal Regulations
(10CFR835.102) requires an internal audit of all elements of a DOE facility’s
RPP every 36 months. The last such audit was done in September 2005. This
audit is intended to satisfy that current 36-month time window requirement for
SLAC as was agreed to by the DOE Stanford Site Office (SSO).
Implementation:
The RP Department Program Manager for each program element of the RPP will
meet with one or more RPP Auditors and/or the Audit Leader and assess the
element per the specific questions above. The Audit Leader will record the
consolidated comments. Each program element review is envisioned to last
between one and two hours. Copies of 10CFR835, the RPP, and the RP ‘Master
Procedure Index’ will be provided during the element evaluation sessions.
Time will be provided to the Audit Team to discuss its findings and to facilitate
development of its audit report. A half-hour will be provided between each
program element. Another half-hour will be provided at the end of each of the
first two days. On the third day, time will be provided from 10:00 AM to the
closeout conference at 2:00 PM for this purpose as well.
Results:
There will be a close-out conference at the end of audit. RP Program Managers
are required to attend. RPP Auditors are encouraged to attend although attendance
is not mandatory. A draft report will be issued at the close-out conference or
shortly afterward. The final report will be issued within 30 days.
Audit Team:
The Audit Team will consist of an Audit Leader, who will be Mike Grissom
(SLAC/ES&HDO), and the following auditors who will assist in carrying out this
audit: Don Cossairt (FNAL), Erik Abkemeier (TJNAF), Henry Khanhauser
(BNL), Harvey Lynch (SLAC/PPA), Steve Frey (SLAC/ES&HDO), and Robin
Wendt(SLAC/OA).
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The following Audit Plan provides the RPP elements to be reviewed, along with names of the RP Program Managers, the RPP Auditors, the dates/times/locations of each RPP Element
evaluation, and suggested records for review. All meetings will take place in Room 126 of Building 24. ‘TBD’ in the Audit Plan means ‘To Be Determined’. Please call either Mike
Grissom at x2346 or Sayed Rokni at x3544 if any questions arise.
Day 1:
Tuesday
12/12/2006
7:00 AM
to 7:30 AM
7:30 AM to 8:00 AM
RPP Element to be Audited
Suggested RPP Program Element Records to
Review
(full set listed in RP ’Master Procedure Index’ at
https://sharepoint.slac.stanford.edu/sites/esh/rp/
Procedures/Forms/AllItems.aspx
Auditor
and
SLAC Audit Staff
Associate
RP Program
Manager
Introductions and Administration
Sayed Rokni
Auditor Training and Badging
Jim Allan
8:30 AM to 9:30 AM
Overview of SLAC RPP
Sayed Rokni
9:30 AM
to
10:00 AM
Radiological Training
&
Access Control
10:15 AM
to
10:45 AM
Dosimetry & Emergency Exposure Situations
10:00 to 10::15 AM
Break
10:45 PM to
11:15 AM
Instrumentation,
Radiological Postings, Radiological Surveys,
and Monitoring
11:15 AM to
11:45 AM
Radioactive Waste Management
11:45 AM to
12:15 PM
Shielding Management & Radiological Design
Issues
12:15 PM to 1:15 PM
Lunch
1:15 PM to 1:45 PM
Planning for Break-Out Sessions
2:15 PM to 4:15 PM
First Break-Out Sessions
4:15 PM to 4:45 PM
Team Caucus (Open - team and program managers
to consider progress and plan details for rest of
review & adjust advanced schedule as necessary)
- RWT I & II Training
- HPT Training and Testing
Henry Kahnhauser,
accompanied by
Mike Grissom
Jim Allan
-
GERT & RWT dose results
Dose histories
Dose investigations
REMS reports
DOELAP Accreditation & findings
Henry Kahnhauser,
accompanied by
Mike Grissom
Henry Tran
-
Entry surveys
RWPs
RadWork Controls for SSRL actinides
RCF Use Procedures
RP Field Operations Logbook/Elog
Instrument inventory
Calibrations
SLAC Rad Lab Procedures
Quality Control
Radwaste inventory control
Radwaste shipping and disposal
DEC Forms
Beam Line Authorizations
Beam Authorization Sheets
Shielding Design Reviews
Radiation Safety Systems
X-Ray Device Approvals
Erik Abkemeier,
accompanied by
Robin Wendt
Jim Allan
and
Henry Brogonia
Erik Abkemeier,
accompanied by
Robin Wendt
Joe Christy
Don Cossairt,
accompanied by
Harvey Lynch
James Liu
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Day 2:
Wednesday
12/13/2006
Activity
7:30 AM to 8:30 AM
Team Caucus
8:30 AM to Noon
Continue Breakout Sessions
Noon
to
1:00 PM
Lunch
1:00 PM
to
4:00 PM
Continue Breakout Sessions
4:00 PM
to
5:00 PM
Team Caucus (Open – Audit Team & RP Program Managers to
consider progress and plan details for rest of review/start draft report
of close-out presentation)
Day 3:
Thursday
12/14/2006
Activity
7:30 AM to 8:30 AM
Team Caucus & Administration
8:30 AM to 10:00 AM
Continue
Break-out Sessions/Finalize Lines-of-Inquiry
10:00 AM
To
Noon
Team Caucus (Report drafting/close-out presentation)
Noon
to
1:00 PM
Lunch
1:00 PM
to
2:00 PM
Team Caucus (finalize close-out presentation)
2:00 PM
to
4:00 PM
Close-out Conference
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