PWS Attachment 6 RFP 75N98020R00014.docx
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PWS Attachment 6
RADIATION SAFETY SURVEY
INFORMATION SHEETS
A routine radiation safety survey has been conducted in your laboratory(ies). Attached are information sheets indicating how to correct items which were found to be out of compliance with the requirements of the NIH radiation safety program. The Division of Radiation Safety (DRS) has developed these information sheets to assist you in implementing corrective measures in a timely manner when problems are identified in your laboratories. Note that the numbers in the left margin of each information sheet correspond to the compliance items on the Radiation Survey Report.
Please take a few minutes to review the information sheet(s). If corrective actions are necessary, please implement them as soon as possible. Be sure to discuss the corrective actions with all individuals who work in your laboratory. If you require additional information or assistance, please contact your Area Health Physicist by calling 301-496-5774, or refer to the DRS web site at http://drs.ors.od.nih.gov.
If you have any comments or suggestions about this system of providing you with the results of routine surveys, please contact DRS with your suggestions.
Your cooperation with DRS in maintaining your laboratories in compliance with the NIH radiation safety program is greatly appreciated!
POSTING AND LABELING REQUIREMENTS
| Each area in which radioactive materials are used or stored must be posted with a | |
| (1) | "Caution Radioactive Materials" sign at the entrance and the NRC Form 3, "Notice to Employees" in a conspicuous location. The required signage was not present at the time of the survey. The surveyor corrected this violation. If additional signs are needed, please contact your Health Physicist by phone or e-mail. |
| Refrigerators and freezers in which radioactive materials are stored must be labeled | |
| (2) | "Caution Radioactive Material". At the time of the survey, a refrigerator or freezer containing radioactive materials was not properly labeled. The surveyor corrected this; however, if additional signs are needed, contact your Health Physicist by phone or e-mail. |
| Any equipment which contains or is contaminated with radioactive materials (pipettors, | |
| (2) | microfuges, etc.), must be labeled "Caution Radioactive Material". During the survey, unlabeled contaminated items were found. The surveyor labeled them. In future, please use "Caution Radioactive Material" tape (available in self-service stores) to label such equipment. |
| Cardboard trays containing used liquid scintillation or gamma vials must be labeled | |
| (3) | "Caution Radioactive Material," with the radionuclide and activity indicated. At the time of the survey, one or more trays of used vials were unlabeled. The surveyor corrected this violation. In future, please use "Caution Radioactive Material" tape (available in NIH self-service stores) to label trays of used vials. |
| Source vials and other containers of radioactive material must be clearly labeled | |
| (4) | "Caution Radioactive Material," with the radionuclide, activity and date indicated. The surveyor identified unlabeled containers of radioactive material. The surveyor corrected this violation. In future, please use "Caution Radioactive Material" tape (available in NIH self-service stores) to label such containers if they are not already labeled. |
| All containers intended for the collection of radioactive waste must first be labeled | |
| (5) | "Caution Radioactive Material". A radioactive waste container was unlabeled at the time of the survey. The surveyor corrected this violation. In future, please use "Caution Radioactive Material" tape (available in NIH self-service stores) to label radwaste containers. |
CONTAMINATION CONTROL
| Absorbent paper must be used on work benches and other work surfaces in which radioactive | |
| (6) | materials are being used. Contamination found underneath absorbent paper or on an uncovered work surface indicates that absorbent paper has not been used properly. Please decontaminate contaminated work surfaces immediately and ensure that absorbent paper is used properly in the future to prevent re-contamination. |
| Gloves must be worn by individuals whenever they are handling any type or quantity of | |
| (10) | radioactive material or are touching potentially-contaminated items or areas. The surveyor observed an individual working with radioactive material or touching potentially-contaminated items without wearing gloves. Please ensure that all individuals who work under your Authorization wear gloves when handling any type or quantity of radioactive material and when touching potentially-contaminated items or areas (e.g., when conducting monthly surveys). |
| A buttoned-up lab coat (or comparable protective clothing) must be worn by each individual | |
| (10) | handling any type or quantity of radioactive material. Please ensure that all individuals who work under your Authorization wear a lab coat when handling any type or quantity of radioactive material and when conducting monthly surveys. |
| ___ | Persons handling unsealed radioactive materials shall not have bare legs or open-toed shoes. |
| (10) | The surveyor observed an individual using radioactive material while having bare legs and/or wearing open-toed shoes. Please ensure that all individuals who work under your Authorization wear proper attire when handling any type or quantity of radioactive material and when conducting monthly surveys. |
| Removable contamination in excess of 2200 dpm (220 dpm for alphas) per 100 cm2 was | |
| (20) | found in the area(s) indicated on the attached diagram. Please decontaminate and re-smear the indicated areas until removable contamination is less than 2200 dpm (220 dpm for alphas) per 100 cm2. |
| Removable contamination in excess of 220 dpm (22 dpm for alphas) per 100 cm2 was found | |
| (20) | in the unrestricted area(s) indicated on the attached diagram. Please decontaminate and re-smear the indicated areas until removable contamination is less than 220 dpm (22 dpm for alphas) per 100 cm2. |
| ___ | Multiple spots of contamination were identified. This indicates a failure to perform adequate |
| (20,24) | surveys after using radioactive materials. In addition to decontaminating and re-smearing the affected areas (see above) ensure that individuals working under your Authorization monitor themselves and their work areas for contamination frequently, at least daily after using radioactive materials. |
| Absorbent paper in the area marked on the diagram was found to be contaminated. Please | |
| (24) | dispose of the contaminated paper as radioactive waste, and line the area with clean absorbent paper. |
| PREVENTION OF INHALATION AND INGESTION |
| OF RADIOACTIVE MATERIAL |
| Chemical fume hoods in which volatile (or airborne) radioactive materials are used must | |
| (7) | have an average air flow of at least 100 linear feet per minute. The chemical fume hood in your laboratory did not have sufficient air flow when measured by the surveyor. Call 301-496-3457 to arrange for repair of the hood so that the average air flow is at least 100 linear feet per minute. In the meantime, do not use the hood for iodinations or other work with volatile radioactive materials. |
| The Division of Occupational Health and Safety (DOHS) requires all chemical fume | |
| (8) | hoods to be calibrated annually. The hood in your lab is either overdue for calibration, or the surveyor was unable to determine when it was last calibrated. No volatile or airborne radioactive materials may be used in the hood until it has been re-calibrated or re-stickered. To schedule a calibration, call 301-496-3457. |
| __ | Eating, drinking, smoking, applying cosmetics, and preparing food and beverages are |
| (13) | prohibited in laboratories and adjacent open areas. The surveyor either observed an individual eating, drinking, smoking, applying cosmetics, or preparing foodstuffs in your posted laboratory, or saw indications that such activities may be occurring. Please remind all individuals working in your laboratory of the rules, and enforce the prohibition on eating, drinking, smoking, applying cosmetics, and preparing foodstuffs in laboratories and adjacent open areas. |
| Food and beverages are not permitted in cold rooms, or laboratory refrigerators or | |
| (13) | freezers. Please remove any improperly-stored foodstuffs and remind all individuals working in your laboratory that food and beverages cannot be stored in cold rooms or laboratory refrigerators or freezers. Also, spot-check your lab periodically for violations of this rule. |
SECURITY/STORAGE OF RADIOACTIVE MATERIAL
| All radioactive materials must be secured to prevent unnecessary radiation exposure to | |
| (9) | personnel and to control access to the materials. When not in use, radioactive source vials must be kept in locked storage. Also, when unoccupied, radioactive materials laboratories are to be secured if radioactive material in experiments in progress or unsecured radioactive waste is present. Please review proper security/storage procedures with your lab staff, and spot-check your lab periodically to ensure that radioactive materials are properly secured. |
| Many newer NIH Buildings on the main campus (Ex. Building 49) strictly prohibit the use | |
| (9) | or storage of radioactive materials in corridors and other unrestricted areas. Please ensure |
| radioactive material associated with your Authorization are never used or stored in | |
| corridors or other unrestricted areas. |
| At NIH facilities other than those listed above, the use or storage of radioactive materials | |
| (9) | in corridors and other unrestricted areas is prohibited, with the following exceptions: |
1) Liquid scintillation and gamma counters may be used in a corridor or other unrestricted area. However, trays of used vials may not be stored on top of the counter or anywhere else in the unrestricted area.
2) Film cassettes are allowed to be stored in the corridor in freezers, provided that the freezer is locked and labeled.
Please review the above corridor storage policy with your lab staff and ensure that all radioactive materials associated with your Authorization are used and stored in accordance with this policy.
SHIELDING
| Shielding may be required for work involving gamma emitters or high-energy beta | |
| (11,19) | emitters to reduce the exposure rate at 10 centimeters to less than 2 mR/hr. The surveyor determined that shielding was inadequate. If you have shielding, be sure that it is positioned properly around source vials and waste containers. If you do not have appropriate shielding, contact your Health Physicist by phone or e-mail. |
Radionuclides Shielding
H-3, C-14, S-35, P-33, Cl-36, Ca-45 None
P-32 3/8 inch lucite
I-125 (> 1mCi) 1/32 inch lead foil or equivalent
Tc-99m (up to 30 mCi) 1/16 inch lead or equivalent
Cr-51 (up to 10 mCi) 1/4 inch lead or equivalent In-111 (up to 15 mCi)
I-131 (up to 5 mCi) 1/2 inch lead or equivalent
Na-22, Fe-59 (up to 1 mCi) 2 inch lead or equivalent
Rb-86 (up to 5 mCi) 1 1/4 inch lead or equivalent
F-18 (up to 15 mCi) 1 1/2 inch lead or equivalent C-11, N-13, Rb-82 (up to 20 mCi) O-15 (up to 25 mCi)
RADIOACTIVE WASTE DISPOSAL
| __ | If radionuclides with both short (less than 120 days) and long (greater than 120 days) are |
| (5) | in the lab, separate waste containers shall be used and labeled to indicate which radionuclides go into which containers. At the time of the survey, radioactive waste was not segregated in this manner. Please remind all personnel of proper waste segregation by half-life procedures. |
| Contaminated items destined for disposal should be placed in appropriate radwaste | |
| (12) | containers immediately rather than being left on benches or elsewhere in work areas. Radioactive waste should not be permitted to accumulate in the lab such that stepcans are overflowing or carboys are overfilled. Radioactive waste pickups can be scheduled, and additional carboys (5-gallon or 2-gallon) and stepcans can be ordered by calling 301-496-4451 or by accessing the portal for Authorized Users at http://ors021oraa.od.nih.gov. |
| Contamination on the floor around radwaste containers is indicative of improper waste | |
| (12) | management; either people are not disposing of radioactive waste in the containers carefully enough, or the containers are overfilled. Please remind your staff to dispose of contaminated items or liquids carefully in the appropriate labeled containers. You may want to place absorbent paper underneath radioactive waste containers to prevent floor contamination. Additional carboys or stepcans can be ordered by calling 301-496-4451. |
| No radioactive waste may be disposed of via the laboratory sink drains. However, the | |
| (12) | surveyor found contamination in the sink drain, which is indicative of improper disposal of radioactive waste. Please remind your lab personnel of proper disposal procedures, and ensure that liquid used to decontaminate items is collected, poured into a carboy and disposed of as radioactive waste. |
| No radioactive waste or labeled items may be disposed of in regular trash containers. If | |
| (12) | uncontaminated, boxes in which radioactive materials were packaged may be disposed of in regular trash after all "Caution Radioactive Material" labels have been removed or obliterated. Potentially-contaminated items should be disposed of as radioactive waste unless proven to be free of contamination. Please remind your lab personnel of proper radwaste disposal procedures as described at https://www.orf.od.nih.gov/EnvironmentalProtection/WasteDisposal/Documents/2014WasteGuide508-09302015.pdf, and routinely check the regular trash in your lab for violations. |
| PERSONNEL DOSIMETERS |
| (Badges) |
| When working with certain types and quantities of gamma emitters and/or high-energy | |
| (14) | beta emitters (P-32, Y-90), individuals are required to wear personnel dosimeters. Each person working with radioactive materials is required to be evaluated for dosimetry. The surveyor observed an individual handling radioactive material without wearing appropriate personnel dosimetry, or the surveyor found someone who has not been evaluated for dosimetry. Please ensure that all individuals working with radioactive materials under your Authorization have (and use) dosimeters if appropriate. To determine whether or not a dosimeter is needed, submit a "Personnel Dosimeter Registration Form"https://drsportal.ors.od.nih.gov/pls/onlinecourse/onlinecourses.portal_course_registration.trainingpage?p_path=dosimetry_form.html to Building 21, Room 139, or fax to 301-496-3544. A dosimeter can be issued immediately if the form is submitted in person Monday through Friday from 8 a.m. to 4 p.m.). If you have any questions about dosimetry requirements, call 301-496-5774. |
ORIENTATION/TRAINING
| __ | A minor under the age of 16 was working with radioactive materials. This must be |
| (15) | stopped IMMEDIATELY. NIH prohibits the use of radioactive materials by minors under the age of 16. |
| __ | Minors who are 16 or 17 years of age are prohibited from handling source vials and must |
| (15) | have special permission from the Radiation Safety Officer to work with other radioactive materials. A minor 16 or 17 years of age was handling source vials or working with radioactive materials without the requisite approval from the Radiation Safety Officer. This must be stopped IMMEDIATELY. |
| __ | Minors 16 or 17 years of age who have permission from the Radiation Safety Officer to |
| (15) | work with radioactive materials (but not source vials) must be directly supervised by an adult NIH staff member at all times. A minor who had approval to work with radioactive materials was not being directly supervised as required. The approval for this minor to work with radioactive materials has been rescinded effective IMMEDIATELY. |
| __ | A minor who is working in a posted lab but not with radioactive material is required to |
| (15) | complete radiation safety orientation at https://drsportal.ors.od.nih.gov/pls/onlinecourse/onlinecourses.portal_course_registration.trainingpage?p_path=start_orientation.html. In addition, the AU is responsible for providing laboratory-specific radiation safety information to the minor. |
| An individual in your laboratory who uses radioactive materials has not satisfied the | |
| (15) | radiation safety requirements listed below. Please remedy this immediately for the individual identified by the surveyor; in future, ensure that all individuals satisfy these requirements before using radioactive materials at NIH. |
The individual must be registered with the Division of Radiation Safety and must register for and complete the first available Radiation Safety in the Laboratory (RSL) course. Call 301-496-2255 or access the portal for Authorized Users at http://drsportal.ors.od.nih.gov .
If an individual needs to begin work with radioactive materials before completing the RSL course, he/she must complete radiation safety orientation at https://drsportal.ors.od.nih.gov/pls/onlinecourse/onlinecourses.portal_course_registration.trainingpage?p_path=start_orientation.html. In addition, the AU is responsible for providing laboratory-specific radiation safety information to the individual. Note, however, that the on-line orientation does not substitute for the RSL and that the individual cannot use volatile radioiodines or protocol quantities of radioactive material before completing the RSL. The Authorized User must provide the necessary oversight to ensure that each individual using radioactive materials under his/her Authorization complies with all radiation safety requirements. This is particularly important for new staff.
DAILY MONITORING
| ____ | A daily contamination survey is required each day after any work with unsealed forms of |
| (16) | radioactive material. A daily survey should cover the hands, lab coat, work area, floor adjacent to the work area, shoes (top and bottom), and potentially contaminated equipment. Any area found to be contaminated must be decontaminated immediately and re-surveyed. Contaminated lab equipment that is dedicated for radioactive material work (and likely to be re-contaminated) should be appropriately labeled. The surveyor was unable to verify that required daily surveys are being performed. |
____ Monitoring with a portable survey meter is acceptable as long as the sensitivity of the
(16) instrument allows for efficient detection of the radionuclides used. Hence, while a NaI probe is recommended when monitoring for I-125, smears surveys must be performed in lieu of a NaI probe for this radionuclide. For radionuclides such as H-3, C-14, S-35, Ca-45, P-33, Cr-51, and Fe-55, a daily survey utilizing smears is required. The surveyor determined that the survey being performed is inappropriate for the radionuclides being used in the lab.
UTILIZATION/DISPOSAL RECORDS
| A radioactive material utilization and disposal record must be maintained for each | |
| (17) | shipment of radioactive material received. These records must be saved for 3 years and must be readily accessible to surveyors. The surveyor was unable to locate the required records. Please ensure that the records are being maintained as required and that they are readily accessible. Yellow "Records" binders may be obtained via your Area Health Physicist at 301-496-5774. |
| Each shipment of radioactive material must have a corresponding radioactive material | |
| (17) | utilization and disposal record documenting each usage of the material, the date, and the manner of disposal associated with each usage. When the vial is empty or no longer in use, the final disposition should be noted on the record and the record faxed to 301-480-9708. Alternatively, you can remove items from your inventory via the portal for Authorized Users at http://ors021oraa.od.nih.gov. The records reviewed by the surveyor were incomplete or inadequate. Please review the above requirements and ensure that your records are maintained properly in the future. |
| ____ | One or more persons who used radioactive material were not designated as users on the |
| (17) | radioactive material utilization and disposal (U/D) record. Individuals who were listed on the original order are pre-printed on the U/D record. If additional people need to use |
the order, the Authorized User is required to add their names to the list of designated users and sign (not just initial) the record. When the vial is empty or no longer in use, the final disposition should be noted on the record and the record faxed to 301- 480-9708.
SURVEY METER REQUIREMENTS
To facilitate daily contamination monitoring, a survey meter must be available to
| ___ | individuals using gamma emitters (other than I-125) or high-energy emitters. For I-125, a |
| (18) | survey meter with a sodium iodide probe is recommended, but not required. The surveyor was unable to locate an appropriate meter for the radionuclides used in the lab. Contact your Health Physicist by phone or e-mail to find out how to obtain an appropriate survey meter. |
| Your survey meter (serial # ) was inoperable at the time of the survey and has | |
| (19) | been tagged as such. Please remove this meter from service and ensure that individuals working with gamma emitters (other than I-125) or high-energy beta emitters have access to a functional survey meter. For I-125, access to a meter with a sodium iodide probe is recommended, but not required. |
To arrange for repair of the meter, contact one of the vendors listed below in alphabetical order.
Clym Environmental Services, LLC (Clym) 5104 Pegasus Court Frederick, MD 21704 301-594-4528
Ecology Services, Inc. (ESI) 10220 Old Columbia Road Columbia, MD 21046 410-381-2600
Radiation Service Organization, Inc. (RSO) P.O. Box 1450 Laurel, MD 20725 301-953-2482
To surplus a meter, verify that it is not contaminated, remove the check source affixed to the side of the meter, and then attach a "Certification that Equipment is Free from Hazards" tag (form NIH 2683) to the meter. Note that the check source must be returned to the Division of Radiation Safety. Contact your Health Physicist by phone or e-mail to arrange for pickup of the source. Do not attempt to send the source via interoffice mail.
| Survey meters must be calibrated initially and annually thereafter. These routine | |
| (20) | calibrations are performed by contract staff and are paid for by the Division of Radiation Safety. The contractor uses a computerized database to track meters. The database is updated based on information obtained during routine surveys. When the contractor locates a meter that needs to be calibrated, the meter will be calibrated within one hour. If you obtain a new meter or if you have a meter that has not been calibrated within the last year, e.g., one that the contractor was unable to locate, please call 301-594-4528 to schedule a calibration. |
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