Radiation Safety Laboratory Inspection Program

Items of Non-compliance

Points Assessed

Radiation worker is unable to articulate and/or demonstrate proper procedures to follow if there is a spill of radioactive material or a personnel contamination incident.

5

A laboratory under suspension used radioactive material.

5

Radiation worker is unable to demonstrate appropriate survey meter use. All radiation workers must be able to demonstrate which meter and detector is appropriate for the radionuclides in use; perform a battery check; and survey the work area.

4

Radiation worker is unable to demonstrate appropriate techniques for smear wipe surveys including locations to survey; avoiding cross-contamination of smear wipes; preparation of smear wipes for counting; interpretation of results; and documentation.

4

Removable contamination >22,000 dpm/100 cm2.

4

All surveys were not performed during periods of use.

4

Radioactive material found unsecured (quantities > Appendix A of OAC 3701:1-38-18)

4

Transfers of radioactive material were not performed according to approved procedures (on or off campus).

4

Laboratory made an unauthorized acquisition of radioactive material.

4

Sharps were not segregated from other solid radioactive waste.

4

Radioactive waste was placed into the biohazard, chemical, or normal waste stream.

4

Personnel did not have the required dosimetry or did not wear it as required.

4

Bioassays were not performed as required.

4

Personnel did not perform or receive radiation safety training prior to using radioactive material (web- based Radiation Safety course and/or initial in-lab training).

4

Evidence of eating, drinking, smoking, application of cosmetics, or mouth pipetting.

4  

Personnel did not wear lab coat, eye protection, or gloves as a minimum to handle radioactive material.

4

Appropriate shielding was not used.

4

A major spill or personnel contamination incident was not immediately reported to Radiation Safety.

4

Failure to submit a completed and signed written corrective action plan.

4

Non-radioactive material worker is unaware of the OSU policy that requires radioactive material to be secured from unauthorized access or removal.

3

Non-radioactive material worker is unaware of the regulation regarding the prohibition of eating, drinking, smoking, applying cosmetics, or mouth pipetting in laboratories posted for the use or storage of radioactive material.

3

Radiation worker is unable to explain the concept and site-specific implementation of an ALARA (As Low As Reasonably Achievable) program including time, distance, shielding, and containment.

3

Radiation worker is unable to explain lab specific procedures for receipt, storage, and security of radioactive material packages. Shipping materials must be smear wiped, free of contamination, and radiation symbols or the word “radioactive” removed or defaced prior to disposal.

3

Radiation worker is unaware of the lab specific procedures for handling low-level radioactive waste including appropriate waste segregation, decay-in-storage, long-lived waste, de minimus waste, mixed waste, and hot sink disposals.

3

Radiation worker is unaware of the lab specific personnel monitoring requirements which may include dosimeter types (whole body, ring) placement and storage, bioassay types (thyroid and urine), and that thyroid bioassays should occur 24-72 hours post use.

3

Radiation worker is unaware of proper posting and labeling requirements in a laboratory using radioactive material including door signs, hot sinks, spill response, and ODH “Notice To Employees” identifying their rights and responsibilities.

3

Radiation workers are not following the proper URSC-approved procedures for handling animals used with radioactive material.

3

Removable contamination >2,200 dpm/100 cm2 but <22,000 dpm/100 cm2.

3

Radioactive material found unsecured (quantities < Appendix A values of OAC 3701:1-38-18 or radioactive material considered low specific activity i.e. radioactive waste).

3

Radioactive waste was not stored in an appropriate container.

3

Radioactive waste containers were not labeled with radionuclide and/or container number.

3

Long-lived radioactive waste was in a lab for a period of greater than 1 year after the container was sealed.

3

Survey meter was not operable or was not within the calibration frequency.

3

Survey meter or detector was not appropriate for the radionuclides used.

3

Annual in-lab training has not been provided and/or is not documented.

3

Equipment used with radioactive material was not labeled “radioactive”.

3

Absorbent pads, bench covers, or trays were not used.

3

University Radiation Safety Committee-approved procedures were not followed.

3

Failure to provide an on-line corrective action response to deficiencies through EHS Assist and/or failure to provide a written record to correct deficiencies.

2

Non-radioactive material worker has not completed the on-line Radiation Safety course*

2

Non-radioactive material worker is unaware of laboratory specific procedures for the receipt and storage of packages containing radioactive material.

2

Non-radioactive material worker is unaware of where radioactive materials are used and stored in the laboratory.

2

Radiation worker is not entering data into EHS Assist at the appropriate frequency or is inaccurately entering disposal information. Radiation workers must be able to navigate EHS Assist or communicate disposal information to the data entry person.

2

Surveys are not documented correctly.

2

Inventory was not maintained on the web-based inventory system or was not entered in a timely manner.

2

Radioactive waste was not segregated according to approved procedures.

2

Decay-storage waste was stored in a lab for greater than 3 years after the container was sealed.

2

Survey meter was not used in the appropriate manner.

2

Dosimetry was not returned after the wear period.

2

Door postings were missing or incomplete.

2

All stock solutions > Appendix A quantities (OAC 3701:1-38-18) were not labeled with radionuclide, activity, and radiation level (as appropriate).

2

Radiation symbols or the wording “Caution, Radioactive Material” was not removed from shipping containers prior to disposal.

2

A minor spill was not reported to Radiation Safety within 24 hours.

2

One-year renewal of a radioactive material permit was not completed.

2

Failure to have a proper maintenance survey performed on labeled equipment prior to relocation or repair.

2

Non-radioactive material worker is unaware of where the spill/personnel contamination emergency response procedure is posted.

1

Radiation worker is unable to explain the laboratory’s site-specific procedures for ordering radioactive materials and that all orders must be approved by Radiation Safety prior to OSURF or Purchasing placing the order with the vendor.

1

Web-based transactions were not entered correctly

1

Failure to label stock vials with EHS Assist inventory number

1

Total Points

Enforcement Action

1-3

The Approved Supervisor of a laboratory that has accumulated 1-3 points shall receive documentation of the deficiencies through EHS Assist. The Approved Supervisor shall correct the deficiencies and document the corrective actions via EHS Assist within 14 calendar days from the date of notification.

If a written record (e.g. RS-6) is required to correct the deficiencies, the Approved Supervisor has 14 calendar days from the date of notification to submit the required information.

Failure to provide an on-line corrective action response to deficiencies through EHS Assist and/or failure to provide a written record to correct deficiencies will result in an additional 2 point violation.

4-7

The Approved Supervisor of a laboratory that has accumulated 4-7 points shall receive documentation of the deficiencies through EHS Assist. The Approved Supervisor shall correct the deficiencies and document the corrective actions via EHS Assist within 14 calendar days from the date of notification. In addition, a written corrective action plan must be submitted within 14 calendar days for review and approval by the University Radiation Safety Committee. If a corrective action plan is disapproved, the Approved Supervisor has 14 calendar days to resubmit a revised corrective action plan. The URSC may designate Radiation Safety to review and approve/disapprove the revised corrective action plan.

If a written record (e.g. RS-6) is required to correct the deficiencies, the Approved Supervisor has 14 calendar days from the date of notification to submit the required information.

Failure to provide an on-line corrective action response to deficiencies through EHS Assist and/or failure to provide a written record to correct deficiencies will result in an additional 2 point violation.

Failure to provide a written corrective action plan for URSC review will result in suspension of the use of radioactive materials until the written corrective action plan has been submitted and approved.

8-11

The Approved Supervisor of a laboratory that has accumulated 8-11 points shall receive documentation of the deficiencies through EHS Assist. In addition, written notification from the URSO will be issued with copies of the letter sent to the appropriate Dean and Department Chair.

The URSO may impose a 2 week suspension of ordering privileges.

The Approved Supervisor shall correct the deficiencies and document the corrective actions via EHS Assist within 14 calendar days from the date of notification. In addition, a written corrective action plan must be submitted within 14 calendar days for review and approval by the University Radiation Safety Committee. If a corrective action plan is disapproved, the Approved Supervisor has 14 calendar days to resubmit a revised corrective action plan. The URSC may designate Radiation Safety to review and approve/disapprove the revised corrective action plan.

If a written record (e.g. RS-6) is required to correct the deficiencies, the Approved Supervisor has 14 calendar days from the date of notification to submit the required information.

Failure to provide an on-line corrective action response to deficiencies through EHS Assist and/or failure to provide a written record to correct deficiencies will result in an additional 2 point violation.

Failure to provide a written corrective action plan for URSC review will result in suspension of the use of radioactive materials until the written corrective action plan has been submitted and approved.

12-15

The Approved Supervisor of a laboratory that has accumulated 12-15 points shall receive documentation of the deficiencies through EHS Assist. In addition, written notification from the URSC Chair, Senior Director for Environmental Health and Safety, and the URSO will be issued with copies of the letter sent to the appropriate Dean and Department Chair.

The URSC Chair will impose a 2 week suspension of the use of radioactive materials.

The Approved Supervisor shall correct the deficiencies and document the corrective actions via EHS Assist within 14 calendar days from the date of notification. In addition, a written corrective action plan must be submitted within 14 calendar days for review and approval by the University Radiation Safety Committee. If a corrective action plan is disapproved, the Approved Supervisor has 14 calendar days to resubmit a revised corrective action plan. The URSC may designate Radiation Safety to review and approve/disapprove the revised corrective action plan.

Failure to provide an on-line corrective action response to deficiencies through EHS Assist and/or failure to provide a written record to correct deficiencies will result in an additional 2 point violation.

Failure to provide a written corrective action plan for URSC review will result in suspension of the use of radioactive materials until the written corrective action plan has been submitted and approved.

16-19

The Approved Supervisor of a laboratory that has accumulated 16-19 points shall receive documentation of the deficiencies through EHS Assist. In addition, written notification from the URSC Chair, Senior Director for Environmental Health and Safety, and the URSO will be issued with copies of the letter sent to the appropriate Dean and Department Chairperson. The Purchasing Agent will also be copied on the written notification.

The URSO will impose suspension of the use of radioactive materials until the URSC rescinds the suspension.

The Approved Supervisor shall correct the deficiencies and document the corrective actions via EHS Assist within 14 calendar days from the date of notification. In addition, a written corrective action plan must be submitted within 14 calendar days for review and approval by the University Radiation Safety Committee. The Approved Supervisor is required to attend the URSC meeting to show cause as to why the URSC should reinstate privileges to use radioactive materials. If a corrective action plan is disapproved, the Approved Supervisor has 14 calendar days to resubmit a revised corrective action plan. The URSC may designate Radiation Safety to review and approve/disapprove the revised corrective action plan.

Failure to provide an on-line corrective action response to deficiencies through EHS Assist and/or failure to provide a written record to correct deficiencies will result in an additional 2 point violation.

>20

The Approved Supervisor of a laboratory that has accumulated 20 or more points shall receive written notification from the Sr. Vice President of Administration and Planning informing the Approved Supervisor that their Approved Supervisor status at The Ohio State University has been suspended for three years. The appropriate Dean, Department Chair, and Purchasing Agent are copied

The Approved Supervisor must cease operations involving radioactive materials immediately and close out all areas posted for the use or storage of radioactive materials. No sanctions are imposed against the users. Users may seek user status under another Approved Supervisor.

During the first year of the suspension, the individual may not use radioactive materials. During the second and third year of the suspension, the individual may use radioactive materials under the supervision of another Approved Supervisor. After three years, the individual may apply to the URSC for Approved Supervisor status.