Ionising radiation safety standard

This standard applies all staff members (including contractors and visitors) and students who use any source of ionising radiation in the University of Auckland.

To ensure that the Fundamental Requirements as laid out in ss 9-12 of the Radiation Safety Act, 2016 will be observed for all sources of ionising radiation in the University of Auckland.

Regulated Sources of ionising radiation are required to have source and user licenses.  Some Regulated Sources may be used under the written instruction from a source license.

Sources of ionizing radiation not requiring a license (low activity radioactive sources which by virtue of their low activity are not Regulated under the Act or those sources exempt from licensing by the Radiation Safety Regulations, 2016) will be supervised by a Responsible Principal Investigator approved by the Dean of each Faculty or Director of Large-Scale Research Institutes. The requirements for all ionizing radiation sources in the University are the same, regardless of whether a license is required.

The University as the holder of source licenses and the Managing Entity reaffirms the primary responsibility of User licensees and Responsible Principal Investigators (as applicable) for the safe custody of all sources of ionising radiation.

The safe use of regulated radioactive material and irradiating equipment will be supervised by current user license, issued by the regulator, the Office of Radiation Safety (ORS). The safe use of unregulated radioactive material will be supervised by a Responsible Principal Investigator.

The University will assist user license holders/Responsible Principal Investigators and the ORS to monitor work with isotopes to ensure that ALARA principles are adopted.

People

1. User license holders/Responsible Principal Investigators must:

• a. Ensure safe use, storage, transport and disposal of isotopes and irradiating equipment. They must meet the statutory requirements of the Radiation Safety Act, its associated Regulations and Codes of Practice promulgated by the Office of Radiation Safety.
• b. Provide adequate supervision and instruction of staff and students using sources of ionising radiation.
• c. Ensure that risk of incurring exposure from any source of ionising radiation is kept As Low As Reasonably Achievable (ALARA).
• d. Maintain accurate records of purchase, transfer, use and disposal of sources of ionising radiation, and ensure these records are available for inspection (by the Radiation Safety Officer (RSO) and the ORS). These records must be retained for at least 10 years.
• e. Report any incidents involving accidental exposure to the RSO. Any overexposure (as defined in ORS Codes of Practice) must be reported to the Director of the ORS within 24 hours. License holders must inform the Head of Department at the same time.
• f. Ensure that any exposure of female staff/students is kept well within the dose rates specified in the applicable ORS Code of Practice.  In the case of declared pregnancy, the dose rates should not exceed 2 mSv during the entire pregnancy. There is also an obligation to ensure that the risks associated with potential exposure to ionizing radiation and pregnancy are fully discussed.

2. All staff and students using sources of ionising radiation, regardless of activity, will receive documented equipment-specific safety induction, prior to using these sources.

3. The estimate of whole-body Equivalent Dose that results from any activity using ionising radiation must not exceed the whole-body dose set for Members of the Public in ICRP 103 (i.e. no more than 1 mSv per annum above background).

4. Any use of ionising radiation on human subjects must have oversight of a user licensee who is in consultation with an appropriately qualified medical practitioner or an accredited medical physicist (if the user licensee is not a medical practitioner or medical physicist). Any use of ionising radiation on human subjects must also have prior approval by a Human Ethics Committee.

5. Any use of ionising radiation on human subjects must follow the applicable ORS Code of Practice.

6. Adequate personal dose-monitoring procedures must be established and documented when recommended or required by an ORS Code of Practice. Dose-monitoring procedures include use of personal monitoring devices for any user, as well as ensuring these devices are distributed, collected and results are collated and recorded.

(Note that personal dose-monitoring is only required for very high activity radioactive sources or irradiating equipment capable of delivering high whole-body dose)

7. Where required by an ORS Code of Practice, records of personal dose-monitoring must be retained for at least 30 years.

(Note that personal dose-monitoring is only required for very high activity radioactive sources or irradiating equipment capable of delivering high whole-body dose).

Equipment and Sources

8. Purchase, transfer or disposal of any source of ionising radiation must not be undertaken without the required statutory approval.

9. Purchase, transfer or disposal of any source of ionising radiation must not be undertaken without required internal University notifications to the RSO.

10.  Equipment capable of emitting ionising radiation must be installed, inspected and maintained in accordance with manufacturer’s instructions, and by a person holding appropriate ORS license. This equipment will also be maintained to the University Machinery and Plant Standard.

11.  Surface dose and or scattered dose of analytical equipment capable of emitting ionising radiation must be measured at least annually. 

Risk mitigation measures to protect operators of equipment such as bone densitometers where scattered dose is a consideration must be assessed at time of installation.

12.  Appropriate survey meters must be available for monitoring work and work areas in which radioisotopes are held and used.

13.  Adequate contamination-monitoring procedures must be established where unsealed and sealed radioisotopes are held and used.

Workplaces

14.  All areas where sources of ionising radiation are stored and used must have adequate access
control to prevent unauthorised entry or access to equipment or sources.

15.  All areas where sources of ionising radiation are stored and used must have adequate warning signage.

16.  Equipment designed to emit ionising radiation must have adequate control over use (such as a key or password) to prevent unauthorised use of that equipment. 

17.  Radioactive sources assigned to Category A and B Security Levels must be stored and used in areas that have access control and security measures specified by the ORS Code of Practice for Security of Radioactive Sources.

18.  All areas where sources of ionising radiation are stored and used must have appropriate and adequate shielding as well as personal protective equipment.

19.  All areas where equipment capable of emitting ionising radiation is used must have clearly visible equipment-specific safety instruction in the form of local rules or local protocols.

20.  Environmental dose surveys for radioactive sources assigned to Category A and B security levels must be undertaken on at least 2-yearly basis.

21.  As far as is reasonably practicable, workplaces where sources of ionising radiation are stored and used must maintain a satisfactory level of housekeeping.

22.  Workplaces where sources of ionising radiation are stored and used must have emergency response plans in place to deal with foreseeable emergencies.

The following definitions apply to this document:

Act means Radiation Safety Act, 2016

ALARA is an acronym for ‘As Low As Reasonably Achievable’ which means maintaining exposure to ionising radiation below regulated limits taking into account the state of technology while weighing the costs and benefits of doing so.

Contamination means the presence of radioactive substances on surfaces or within solids, liquids or gases (including the human body), where their presence is unintended or undesirable (from the International Atomic Energy Agency (IAEA) definition).

Control is an item or action designed to remove a hazard or reduce the risk from it.

Equivalent Dose (Sieverts) is a measure of the radiation dose to tissue where an allowance is made for the different relative biological effects of different types of ionising radiation. The equivalent dose is used to measure the stochastic health effects of low levels of ionising radiation on the human body and the probability of radiation-induced cancer and genetic damage. The Equivalent Dose is calculated by multiplying absorbed dose (in Grays) by the weighting factor, or relative biological effectiveness (RBE), for the type of radiation involved.

Fundamental Requirements are the essential requirements to protect people and the environment from the adverse effects of ionising radiation and are laid out in ss 9-12 of the Radiation Safety Act, 2016

Hazard refers to anything that has the potential to cause harm (injury or ill-health) or damage to property or equipment in connection with a work activity.

ICRP 03 refers to the International Commission on Radiological Protection Publication 103 - The 2007 Recommendations of the International Commission on Radiological Protection

Incident is any unplanned event resulting in, or having a potential for injury, ill-health, damage or other loss.

Induction is a formal process to inform a person entering a workplace of local rules, procedures and safe work practices that will enable the person to safely carry out work, study or research. The level of the information provided may vary to cater for a person's role (visitor, student, contractor, staff member etc.) or the level of risk within a workplace.

Irradiating equipment (from the Radiation Safety Act 2016) is electrical equipment that is designed to generate ionising radiation (e.g. x-ray equipment).

Managing Entity is the legal entity that ultimately manages or controls radiation sources. In a teaching and research setting in the University, the Managing Entity is the University of Auckland.

ORS means Office of Radiation Safety

Office of Radiation Safety (ORS) is part of the Ministry of Health and administers the Radiation Safety Act 2016 and the Radiation Safety Regulations 2016 on behalf of the New Zealand Government.

ORS Code of Practice is a code of practice issued by the ORS under section 86 of the Radiation Safety Act 2016

Personal protective equipment (PPE) refers to anything used or worn by a person to minimise risk to the person's health or safety. PPE relevant to use of sources of ionising radiation includes appropriate clothing and safety equipment such as gloves and shielding appropriate for the ionising radiation being emitted. 

Protocol A system that explains how to manage a health and safety subject, consisting of a formal set of documents; standards, procedures, training matrices, guidance, forms, monitoring documents and frequently asked questions. 

Radiation Safety Officer (RSO) The Radiation Safety Officer is a competent person who is appointed by the Associate Director, Health, Safety and Wellbeing on behalf of the University. The RSO is required to be knowledgeable in the evaluation and control of ionising radiation hazards. 
The RSO provides oversight on the control of ionising radiation hazards and risk at the University on behalf of the University as Managing Entity.

Radioactive Material means any material that spontaneously emits ionising radiation, including any naturally occurring radioactive material or any nuclear material

• Regulated Radioactive Material means radioactive material whose activities meet the definition of ‘radioactive material’ under s4 in the Radiation Safety Act 
• Unregulated Radioactive Material means radioactive material whose activities do not qualify as ‘radioactive material’ under s4 in the Radiation Safety Act.

Risk refers to the likelihood a hazard will cause harm (injury or ill health) and the degree of harm
(consequence). Residual risk is the risk that remains after controls have been applied to a hazard. 

Responsible Principal Investigator is a Principal Investigator approved by the Dean of each Faculty or Director of Large-Scale Research Institutes to be responsible for a source of ionising radiation that does not require a source and use license

Risk assessment is the process of evaluating the risk(s) arising from a hazard(s), taking into account the adequacy of any existing controls, and deciding whether or not the risk(s) is acceptable. 

Security Levels are categories for high activity radioactive materials under which different security measures must be taken. The security level is defined in the ORS Code of Practice for the Security of Radioactive Material and is primarily determined by the activity, half-life and the energy of radioactive emission of the isotope concerned. Security level A is the category requiring the most stringent security measures.

Sources of Ionizing Radiation include Radioactive Material and Irradiating Equipment

• Regulated Sources of Ionizing Radiation means radioactive material whose activities meet the definition of ‘radioactive material’ under s4 in the Radiation Safety Act or irradiating equipment requiring a license under the Act.
• Unregulated Sources of Ionizing Radiation means radioactive material whose activities do not qualify as ‘radioactive material’ under s4 of the Radiation Safety Act, 2016 or irradiating equipment exempt from requiring a license under the Radiation Safety Regulations, 2016.

Survey Meters means hand-held ionising radiation measurement instruments used to check personnel, equipment and the environment for radioactive contamination and ambient radiation.

University means the University of Auckland and includes all subsidiaries.

Visitor refers to any person lawfully entering a workplace who is not authorised to use or operate
the machinery or plant within.

Workplace is any physical location in which work-related activities are performed under the control of the University. 

Document Control
Version: 1.0
Last Updated: Aug 2020
Next Review: Aug 2023
Owner: hsw@auckland.ac.nz
Approver: Associate Director, Health Safety & Wellbeing