Radiation Protection Unit Annual Report 2012 / 2013

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1 The University of Edinburgh C University Health and Safety Committee Tuesday 5 th November 2013 Radiation Protection Unit Annual Report 2012 / 2013 Brief description of the paper This Paper presents the Annual Report for the academic period 2012/2013, from the University Radiation Protection Adviser. The Paper summarises the work of the Radiation Protection Unit (RPU) over this period and includes information on staff, incidents, enforcement visits and action, training, new sources and radiation applications, Radiation Protection Unit work and future work. Action requested Resource implications Risk Assessment Equality and Diversity Any other relevant information Originators of the paper For Information Does the paper have resource implications? No Does the paper include a risk analysis? No Does the paper have equality and diversity implications? No Presented by Colin Farmery, University Radiation Protection Adviser Colin Farmery Freedom of information Can this paper be included in open business? Yes If no, please indicate which of the reasons below justifies the paper being withheld. Its disclosure would substantially prejudice a programme of research Its disclosure would substantially prejudice the commercial interests of any person or organisation Its disclosure would constitute a breach of the Data Protection Act Its disclosure would substantially prejudice the effective conduct of public affairs Its disclosure would constitute a breach of confidence actionable in court Other (please give further details) For how long must the paper be withheld? (express either as the time which needs to pass or a condition which needs to be met.).

2 C Radiation Protection Unit Annual Report 2012 / 2013 A Paper submitted to the Health and Safety Committee Meeting, 5 th November 2013, by Colin Farmery. 1. Staff The Assistant Radiation Protection Adviser (ARPA) has now received a Certificate of Recognition to act as a Radioactive Waste Adviser as required by the Certificates of Authorisation issued under the Radioactive Substances Act (in Scotland) (RSA). This recognition was issued under grandfather rights, and only required confirming in writing that he had worked on RSA matters. More stringent requirements have since been introduced requiring applications to be approved by an accreditation body and accompanied by an appropriate portfolio of evidence. The Radiation Protection Superviser (RPS) role for the Scottish Centre for Regenerative Medicine has been taken on by their Technical Manager, although he is receiving help from the Assistant RPS at the School of Biological Sciences at King s Buildings. The RPS for the Roslin Institute will shortly be passing her RPS responsibilities to another RPS at the Easter Bush campus. 2. Incidents Although there were no known ionising or non-ionising significant radiation exposures during the period, there were two incidents of note. One was a high reported extremity dose to a veterinary nurse, and the other was a reported overdose to a veterinary surgeon. 1) High Dose Reading A dose of 120 msv was recorded on an extremity dosemeter worn by an employee. It was subsequently determined that there was no significant dose on his whole-body dosemeter worn during the same period. This dose is very close to the annual limit of 150 msv, and exceeds the University s Dose Investigation Level for this work, so a formal investigation was required. It was not however an overdose, and the Health and Safety Executive (HSE) did not need to be informed. The wearer was not required to undergo extremity dosimetry previously in this calendar year, and so this dose was expected to be an accurate assessment of his extremity dose for the calendar year so far. Only one activity involving radiation had been undertaken by the employee during the wearing period, and the investigation was therefore able to centre on this. This activity involved the application of a short-lived radioisotope to horses and their subsequent diagnosis in a dedicated facility; the technique is known as equine scintigraphy. The wearer was not aware of any other circumstance during this wearing period when this dosemeter might have been exposed to radiation. There was therefore no reason to think that the reading was false. Paper C - RPU Annual Report

3 1) High Dose Reading (cont.) The wearer and his supervisor had already reviewed his procedure, and stated that the only deviation from normal was that he had worn the dosemeter on the outside of his glove. They therefore proposed that the dose actually arose from a drop of the radioactive solution contaminating the dosemeter. The wearer had not carried out any contamination monitoring on himself following the procedure, so there is no way to verify this suggestion by observation of the contamination monitoring records. The explanation is feasible, but it is most unlikely that a single drop of technetium would have fallen onto the wearer during the procedure. It is therefore reasonable to assume that there were other areas of personal contamination, and potential skin irradiation. The average dose to the extremities received by other members of staff undertaking this work in 2013 is trivial. We have therefore concluded that the best available explanation at this time is that the high dose arose from this contamination scenario, and we have not asked for an annotation of the wearer s dose records. It is worrying that the wearer had not monitored himself for contamination after handling a very high specific-activity radioactive liquid. It is a fundamental and essential part of the safety measures for working with radioactive material. The employee had attended the relevant training course, and the need for contamination monitoring is incorporated in the Local Rules. During the discussions, it was also noted that there had been no local instruction on, or supervision of, the procedure for the intravenous administration of the radioactive material. Recommendations were made to the Veterinarian in charge of the Equine Scintigraphy Unit, and the wearer s line manager on improving contamination monitoring procedures, instruction and supervision and the need to monitor dosemeter results carefully. 2) Overdose Reading Whilst scrutinising the dose results for the Veterinary staff, Radiation Protection Unit (RPU) staff became aware of a high dose reading on the whole-body dosemeter worn by a senior veterinary surgeon working with x-ray imaging. The dose reading was a whole-body depth dose of 50 msv, for an eight-week wearing period. The relevant Dose Investigation Limit is 1 msv per dosemeter, but the dose is also in excess of the annual dose limit of 20 msv. If the dose were a true reading, it would have required immediate suspension from work with ionising radiation, a medical examination, and notification to the HSE. The RPU immediately contacted the Royal (Dick) School of Veterinary Studies to investigate, initially, whether this dose was genuine. The wearer however was confident how the dose had come about. He had unknowingly dropped his dosemeter on the table of the x- ray set, and only became aware of it after the x-ray examination had taken place. The dosemeter could be seen on the x-ray image. He confirmed that he was not aware of any other incident during the wear-period that may have resulted in a high dose reading to his dosemeter. Although the x-ray exposure parameters were known, it would have been quite difficult to replicate the actual dose delivered to the dosemeter, so no attempt was made. It is feasible that this level of dose could be achieved in a typical CT scan. The dose results for all veterinary staff involved in diagnostic imaging for the same wear period were reviewed, and no doses above the limit of detection levels were observed. The RPU was therefore confident that the dosemeter was not being worn at the time that it received the dose, and the wearer has not received an overdose. The reading was not reported to the Health and Safety Executive, and we have written to the dosemeter laboratory asking them to make a special entry into the wearer s dose records. Paper C - RPU Annual Report

4 2) Overdose Reading (cont.) Unfortunately the wearer continued to wear the dosemeter for routine work for a while after, and it is worrying that this incident was only brought to the attention of the University Radiation Protection Unit when they reviewed a regular dose report from the dosemeter laboratory. The incident was not reported to the RPU by the member of staff dealing with the dosemeters, the wearer or the dosemeter laboratory. As a result of this incident, the RPU has written to all the University RPSs, and to the dosemeter laboratory, to remind them of their roles in monitoring dose results. 3) Enforcement Visits and Action Three visits were made to the University during the period by the Health and Safety Executive radiation specialist inspector. They were all to do with the X-ray Fluorescence (XRF) analyser reported below in Section 5. A Scottish Environment Protection Agency inspector undertook twelve inspections of the following University premises. All visits were routine save the one to the old Roslin site, which was to inspect premises that had been decommissioned. School of Chemistry, Joseph Black Bldg. School of Biomedical Sciences, Hugh Robson Bldg. School of Engineering, William Rankine Bldg. Old Roslin Laboratories Little France Easter Bush Radiation Protection Unit, Charles Stewart Ho. School of Physics, JCMB School of Biological Sciences, Ashworth Labs., Swann & Darwin Bldgs. School of Biomedical Sciences, 1, George Sq. School of Molecular, Genetic & Population Health Sciences, Western General Hospital School of Chemistry & RPU Store, Joseph Black Bldg. All of the inspections were satisfactory, and there were no significant adverse comments. There were a number of visits by the Counter Terrorism Security Adviser (CTSA) to inspect the security measures for the University s High Activity Sealed Sources (HASS). The CTSA also inspected the RPU s own sources unannounced; one of these sources is considered to be a source of a similar level of potential hazard, as defined in the HASS regulations. There were no adverse comments of the RPU sources and we are not aware of any significant adverse comment elsewhere. The CTSAs have made verbal comments about personnel security checks, but are so far satisfied with the University s existing arrangements. 4) Training Five Basic Radiation Protection Courses in Research and Teaching, three Radiation Protection Courses in Veterinary Diagnosis and Therapy, and four Laser Safety Courses were provided. Work on developing a RPS on-line training course continues. The University Radiation Protection Adviser (URPA) also gave two lectures in his own time on radiation emergency arrangements to representatives of the Scottish Fire and Rescue Services at the Fire Service College, Gullane. Paper C - RPU Annual Report

5 5) New Sources and Radiation Applications The Royal (Dick) School of Veterinary Sciences (R(D)SVS) is progressing with the provision of a Positron Emission Tomography (PET) facility for small animals. The PET scanner is located in the same room as their Computerised Tomography (CT) scanner in the Hospital for Small Animals. The radioisotope, fluorine-18, will be obtained from the Clinical Research Imaging Centre (CRIC) and transported to R(D)SVS facilities at Easter Bush by Veterinary support staff. The RPU have provided advice on the facility s radiation protection requirements and procedures, and have given training on the transport of the radioactive material. R(D)SVS have purchased a mobile x-ray set for research work with pigs. This type of x-ray set provides the ability to obtain dynamic fluoroscopic images of the patient. The set is located in an operating theatre at the Moredun Research Institute. The RPU have undertaken a survey of the equipment and location. Radiological protection aspects have been complicated by a lack of clarity on the procedures intended, the fact that the location is temporary, and that the staff external to the operating theatres are not employed by the University and therefore have to be treated as members of the public. R(D)SVS is also equipping out one of their theatres to undertake interventional radiology. Interventional radiology involves staff being much closer to the patient and x-ray set than conventional radiography, and having to use long x-ray exposure times. A survey indicated high scattered instantaneous radiation levels, and recommendations have been made to shield the doors to the room and, unusually, provide shielded spectacles for the radiologist and associated staff. A critical examination was carried out on behalf of the installer of the new diagnostic x-ray equipment in one of the Hospital for Small Animals radiography rooms. Critical Examinations are the legal responsibility of the installer, but it is commonplace for the client s radiation protection expert to be involved in the examination. R(D)SVS are also intending to acquire a surgical laser, initially for the purposes of canine laser lithotripsy, which is the in-vivo disintegration of bladder stones. The nature of the use precludes enclosure of the laser beam, and the staff inside the room will need to follow careful procedural control measures. The RPU have given advice on the standards required for the room, and has provided a training course for the relevant veterinary staff. The School of Molecular, Genetic and Population Health Sciences acquired a Class 4 laser for research purposes at the Edinburgh Cancer Research Centre. The RPU became aware of this by a circular route, and when visited found the laser was being used with an open invisible Class 4 beam and no effective precautions taken to prevent persons entering the room. The researcher was asked to cease use of the laser until effective arrangements were in place, which have now been done. In order to assist NHS Lothian, who wishes to partake in a research project that requires using unsealed yttrium-90 at the CRIC, the RPU has applied for and received a Variation Notice to the Certificate of Registration for Little France, even although the work is not a University activity. The School of History, Classic and Archaeology has purchased a handheld X-ray Fluorescence analyser for elemental analysis of archaeological artefacts. The School had not followed the standard arrangements for beginning work with radiation sources, and the RPU became aware of it through a general safety visit. On undertaking a survey, it became apparent that not only was the device software controlled, but there were intermittent faults with the software control, Paper C - RPU Annual Report

6 5) New Sources and Radiation Applications (cont.) resulting in the device sometimes generating x rays when not instructed, and sometimes failing to cease x-ray generation when instructed to do so. The School was asked to cease using the device until further notice. Since the device had presumably been sold to the University in this state, the Health and Safety Executive was contacted. The HSE decided to take the device into their possession for further investigation, and therefore visited to confiscate it. We currently await the HSE s comments. The HSE inspector has asked that the University looks at its arrangements for ensuring that it is in a position to be able to carry out radiation risk assessments on new acquisitions prior to their use. Discussions have been held with Procurement Office, although a reliable automatic notification arrangement appears unlikely. A researcher has joined the School of Geosciences who intends to work with small quantities of radioactive actinides to simulate naturally occurring radioactive material in the environment. The radiological risk is low but, ceteris paribus, involves the application for new Certificates of Registration and Authorisation for the School of Geosciences. It has been agreed with the School of Chemistry and the SEPA to apply for a new pair of Certificates that cover the Schools of Geosciences and Chemistry at King s Buildings (KB) and the RPU store at KB. This will increase the number of buildings covered by RSA Certificates, but at the same time reduce the number of University RSA Certificates by one. The Certificates application has been prepared and will be submitted shortly. 6) Radiation Protection Unit Work A great deal of time has again been spent preparing applications for new or modified RSA Certificates or requesting cancellations. The following summarises the applications and cancellations requested and processed with the SEPA during this period. Premises Western General Hospital Old Roslin Institute Little France Grant Institute, Joseph Black Bldg., and RPU store Why To account for the merger of the Human Genetics Unit To cancel the Certificates To permit a NHS Lothian research project to go ahead at the CRIC To permit work with radionuclides in the Grant Institute, and consolidate two sets of Certificates Date Submitted 14 th Sept nd Nov th March 2013 Imminent - Date Received 29 th Nov st March th May 2013 The University now has 23 Radioactive Substances Act Certificates; the latest move will reduce this to 22. A survey was carried out of a radiography room in Geosciences, of the CT scanner at the R(D)SVS, and of the research irradiators, as well as the new radiation sources mentioned elsewhere in this review. Assistance was also provided to the Scottish National Blood Transfusion Service over quality issues with their blood-bag irradiator, and a researcher at the Roslin Institute who wanted to irradiate only part of a sample. Paper C - RPU Annual Report

7 6) Radiation Protection Unit Work (cont.) The RPU hosted the 2013 conference of the Association of University Radiation Protection Officers on the 3 rd, 4 th and 5 th of September Hosting involved arranging the venue for the conference in Accommodation Services, a social evening at the City Chambers, a formal conference dinner at the Playfair Library, and a trip to Torness nuclear power station. This involved a considerable commitment of time both from the RPU and the Health and Safety Department s administrative staff. We are pleased to say that the conference went without a hitch and we have received favourable comments; we hope that it will have enhanced the University s standing within the university sector. Two Radiation Safety Codes of Practice have been issued during the period. One provides advice on the requirements for radiation Classified Workers, and the other on the precautions required for researchers working with radiation at sites overseas. To support these CoPs, a new Proposed Scheme of Work form is being drafted to cover work with radiation external to the University. The Health and Safety Adviser within the Occupational Hygiene Unit, in liaison with the RPU and the Biological Safety Adviser, has developed with Information Services a software system for accounting for biological, radiological materials, which is also intended to provide the monthly reporting facility for radioactive material holdings and disposals to the RPU. It is currently in the pilot stage, in order to populate the database and test its capabilities. 230 radiation instruments and 82 source leakage tests were carried out. 102 Proposed Scheme of Work forms have been processed, although processing proposed Scheme of Work forms is delayed at the moment due to other work commitments. 7) Future Work We remain hopeful in making some progress on the following issues: The production of a new radiation section of the University Health and Safety Policy. The introduction of an accounting scheme for uranium and thorium and its compounds. The continuing provision of generic risk assessments for ionising radiation applications. The preparation of generic risk assessments for lasers and the modification of the current Laser User Registration form to permit specific risk assessment. The provision of guidance on personal dosimetry. The computerisation of the Proposed Scheme of Work system. The provision of guidance on the transport of radioactive material outside of the University. The introduction of a system to allow for reliable regular radiation equipment surveys. Checking the consistency of waste disposal arrangements in line with the current mix of RSA Certificate requirements. Undertaking radiation safety auditing. Completing a roll-out of the new Exemption Order and RSA Regulations. Arranging regular meetings of RPSs. C. S. Farmery University Radiation Protection Adviser 23 rd October 2013 Paper C - RPU Annual Report

RP COP001 Radiation Protection Supervisors

RP COP001 Radiation Protection Supervisors 1. Introduction This Code of Practice (CoP) concerns University staff or postgraduate students who are, or are about to be, appointed as Radiation Protection