UNIVERSITY OF VICTORIA X-RAY EQUIPMENT SAFETY POLICIES AND PROCEDURES

UNIVERSITY OF VICTORIA X-RAY EQUIPMENT SAFETY POLICIES AND PROCEDURES Department of Occupational Health, Safety and Environment November 2009

TABLE OF CONTENTS 1.0 PURPOSE 2 2.0 SCOPE AND APPLICATION 2 3.0 RESPONSIBILITIES 3 3.1 Radiation Safety Committee 4 3.2 Radiation Safety Officer 4 3.3 Department Head 5 3.4 Principal Investigator 5 3.5 X-Ray Equipment Supervisor 6 3.6 X-Ray Equipment User 7 3.7 Maintenance Personnel 8 4.0 PROCEDURES 4.1 Purchasing 9 4.2 Registration of X-Ray Equipment 9 4.3 Facilities 10 4.4 X-Ray Equipment Safety Inspections 10 4.5 X-Ray Signs and Warning Signals 10 4.6 Laboratory Security 11 4.7 Training 11 4.8 Dosimeters 12 4.9 Exposure Limits 12 4.10 Survey Meters 13 4.11 Pregnant Personnel 13 4.12 Accidents & Emergencies 13 4.13 Compliance & Enforcement 13 5.0 RESOURCES 14 APPENDIX 1: X-Ray Equipment Registration Form APPENDIX 2: X-Ray Equipment Safety Audit APPENDIX 3: Safety Code 32: Pre-Operational Safety Checks November 2009 1

1.0 PURPOSE Analytical x-ray equipment refers to those systems that contain an x-ray tube (or sealed demountable tower) as the source of ionizing radiation. This generally refers to all types of x-ray diffraction and spectrographic systems designed primarily for determining elemental composition or to examine the microstructure of materials. The primary objectives of the x-ray equipment safety program are: to keep all exposures to x-ray radiation as low as reasonably achievable (ALARA), and to operate x-ray equipment in accordance with all federal and provincial regulations and UVic policies and procedures. 2.0 SCOPE AND APPLICATION Analytical x-ray equipment used in research laboratories can utilize intense x-ray beams. Potential exposures to the primary beam in an analytical x-ray unit may be as great as 1,000 Sv/min. However over the years, design requirements have improved the safety of analytical equipment; and the most common hazards that remain are due to operator errors and equipment malfunctions. This program applies to all departments, supervisors, employees, students, visiting scientists, and technicians who work with or work around analytical x-ray equipment, including during repair or beam alignment of analytical x-ray equipment, at the University of Victoria. This manual in conjunction with provincial and federal regulations provides a framework for creating a safer environment for all individuals on campus. November 2009 2

3.0 RESPONSIBILITIES Personnel in every location where analytical x-ray equipment is installed for use must strictly adhere to the responsibilities charged to them. Every person owning, installing, supplying, operating or servicing analytical x-ray equipment shall take all reasonable precautions to protect all individuals from exposure to x- rays. Figure 1 outlines the general organizational structure on campus, with the Radiation Safety Officer acting as the liaison between all groups. The responsibilities given to the various individuals and groups on campus are outlined below. Figure 1: General Overview of Organizational Structure November 2009 3

3.1 RADIATION SAFETY COMMITTEE (RSC) Make recommendations to the Vice-President Finance and Operations concerning radiation safety measures for all personnel working at the University; Review all proposed uses of analytical x-ray equipment at the University; Recommend procedures for the monitoring of radiation exposure of all individuals working with or in the vicinity of functioning analytical x-ray equipment; Be available for consultation on issues dealing with ionizing radiation; Investigate any violation of policies concerning any form of ionizing radiation and to recommend corrective measures to the Vice-President Finance and Operations. 3.2 RADIATION SAFETY OFFICER (RSO) The Radiation Safety Officer at the University of Victoria is responsible for monitoring compliance with the requirements given in this manual. The Radiation Safety Officer is required to: Implement a system of verification and periodic review to ensure that responsibilities assigned to applicable personnel are carried out in accordance with federal and provincial regulations and university policy; Make readily available a copy of this manual for reference by users and maintenance personnel; Ensure that the necessary records required by government regulations are maintained including compliance verification reports, training records, lists of analytical x-ray equipment users and exposure reports; Investigate all x-ray equipment related accidents and initiate appropriate action including the preparation of reports for regulatory agencies. November 2009 4

3.3 DEPARTMENT HEAD The Department Head has the following responsibilities within the program: Identify all principle investigators utilizing x-ray sources under his/her authority and ensure that they clearly understand their duties and responsibilities as individuals with principle authority for x-ray sources; Ensure that all components of the University of Victoria Analytical X-ray Protection Program are implemented in the department. 3.4 PRINCIPAL INVESTIGATOR (PI) The Principal Investigator is one who is in charge of an x-ray source laboratory and/or the principal authority for x-ray sources, usually a faculty member. The Principal Investigator may delegate some or all of their responsibilities to an X-ray Equipment Supervisor. However, the Principal Investigator cannot discharge these responsibilities to the X-ray Equipment Supervisor. The PI is the person listed on the registration certificate. This individual must be knowledgeable of the requirements for analytical x-ray equipment safety, potential x-ray hazards, associated control measures, and the policies, practices and procedures pertaining to the x-ray equipment under the PI s control. The principal investigator has the following responsibilities: Register all x-ray equipment before use and deregister any decommissioned pieces of equipment with the Radiation Safety Officer in the Department of Occupational Health, Safety & Environment; Identify all x-ray sources, supervisors and workers under his/her authority to the RSO; Ensure that all x-ray equipment is installed in accordance with the facility safeguard requirements; Ensure that all users have received training on the proper operation and the x-ray hazards appropriate to the analytical x-ray equipment installed; Provide and enforce the use of appropriate personal protective equipment when required; November 2009 5

Ensure the wearing of a personal dosimeter by all x-ray workers when necessary, as deemed by the Radiation Safety Officer; Post prominently near the x-ray equipment radiation safety rules, and safe operating and emergency procedures; Make readily available a copy of this manual and Health Canada Safety Code 32 for reference by users and maintenance personnel; Implement a system of verification, supervision and periodic review to ensure that all users and maintenance personnel have received adequate training, and have read and understood the relevant parts of this manual, the applicable radiation safety rules, safe operating and emergency procedures before using and servicing the x-ray equipment; Establish a maintenance program, taking into account the age and frequency of use, that ensures all safety devices and components critical to both x-ray production and shielding, are checked and defective parts replaced or repaired; Provide an appropriate survey meter, and ensure that it is in a working and functional condition at all times; Conduct prompt investigations of all radiation overexposures and accidents, and submit appropriate reports to the Radiation Safety Officer in a timely manner. 3.5 X-RAY EQUIPMENT SUPERVISOR The Equipment Supervisor is an individual who is delegated supervisory responsibility for x-ray sources and/or x-ray workers by the Principal Investigator. The Equipment Supervisor may take over responsibility for some or all of the responsibilities outlined under Principal Investigator in this manual. November 2009 6

3.6 X-RAY EQUIPMENT USER X-ray equipment users are individuals authorized by the Principal Investigator and the Radiation Safety Officer to work with or near x-ray equipment. X-ray equipment users must: Receive training authorized or approved by the RSO on the operation and radiation hazards relevant to the x-ray equipment intended for use; Understand and follow all applicable radiation safety rules and emergency procedures that are prescribed by the Principal Investigator and the RSO; Wear radiation dosimeters to monitor separately whole body and extremity doses as deemed appropriate for the operation(s) being undertaken and/or as recommended by the RSO; Use a survey meter to identify and monitor radiation levels at critical areas (tube housing, beam ports, shutters, analysis accessories, etc.) of the equipment during set up and beam alignment procedures, and following modifications and/or alterations to a device or its accessories, and to ensure that compliance with the regulatory limit (5 µsv per hr at 5 cm from any external surface of the equipment) is maintained. Use an appropriate survey meter to identify and monitor radiation levels to ensure that permissible dose limits would not be exceeded under routine operational conditions of the equipment; Conduct pre-operational safety checks (refer to Appendix 3); Stop the operation of the x-ray equipment if any unsafe operational conditions arise, and immediately notify the Principal Investigator; Take all-reasonable precautions to ensure the equipment user s safety and the safety of fellow workers; Report all unsafe conditions, incidents and/or exposures to the Principal Investigator and the RSO. November 2009 7

3.7 MAINTENANCE PERSONNEL Maintenance personnel are individuals who are trained and authorized to perform alignments, upkeep, maintenance or repairs of analytical and cabinet x-ray equipment. All maintenance personnel must: Be adequately trained in the maintenance and repair of the x-ray equipment for which they are responsible, with emphasis on maintenance operations that may require x-ray production; Have read, understood and follow all radiation safety rules, requirements and emergency procedures applicable to the x-ray equipment and facility, including the guidelines on operational safety and exposure monitoring; Wear radiation dosimeters to monitor separately whole body and extremity doses as deemed appropriate for the operation(s) being undertaken; Use a radiation survey meter to identify and monitor the radiation levels at critical areas (tube housing, beam ports, shutters, analysis accessories, etc.) of the equipment during set up, beam alignment and maintenance, and following modifications to the device or its accessories; Undertake precautionary measures to eliminate or reduce radiation levels (measure according to the preceding clause) to ensure that the regulatory limit (5 µsv per hour 5 cm from any external surface of the equipment) is met, and that guidance levels including the permissible dose limits would not be exceeded during routine operational conditions of the equipment; Perform regular reviews of their own personal dosimetry data and identify unexpected radiation exposures, investigate them as to root cause(s) and implement appropriate corrective actions(s) as may be necessary; Provide the user and the equipment owner or designee with a written report that specifies explicitly any user procedure or action that could lead to an x-ray hazard, as soon as such a procedure or action is identified; Adhere to the maintenance safeguards outlined in this manual; Supervise the work of maintenance personnel in training; Prevent the operation of the analytical x-ray equipment if any unsafe operational conditions arise, and immediately notify the Equipment Supervisor, Radiation Safety Officer or designee of such conditions. November 2009 8

4.0 ADMINISTRATIVE PROCEDURES 4.1 PURCHASING Any proposed purchase or acquisition of x-ray equipment or x-ray emitting devices must be reviewed and considered for approval in advance by the Radiation Safety Officer and Radiation Safety Committee. 4.2 REGISTRATION OF X-RAY EQUIPMENT All equipment at the University of Victoria that is capable of producing x-rays must be registered with the RSO in the Department of OHSE. There are two main reasons for maintaining a record of all X-ray sources. To: i. Identify areas where x-ray sources are present so that appropriate administrative and engineering controls may be put in place; ii. Enable an x-ray source to be inspected on a regular basis for compliance with Health Canada Safety Code 32 and the Universities Analytical X-Ray Protection Program. The Principal Investigator is responsible for the registration of all x-ray sources and deregistration of any decommissioned sources. To register equipment please complete Form 1A: Equipment Registration (Appendix 1). Upon approval of registration by the Radiation Safety Committee, an internal registration certificate will be issued to the Principal Investigator responsible for the equipment. Each internal registration certificate will have an expiry date at which time renewal will require approval of the Radiation Safety Committee. Each certificate may also contain specified conditions of approval, compliance with which is to be mandatory. Any changes to equipment, location or purpose of use will require recertification by the Radiation Safety Committee. No work may proceed without a valid certificate. November 2009 9

4.3 FACILITIES Analytical X-ray equipment is to be used only in those laboratories that conform to the specification of Health Canada s Safety Code 32 and, Analytical X-ray equipment is to be used only in those areas designated on the internal registration certificate and, Access to analytical x-ray equipment is limited to those authorized by the Principal Investigator and those who have received appropriate radiation safety training and authorization as determined by the RSO. 4.4 X-RAY EQUIPMENT SAFETY INSPECTIONS Regular inspections of x-ray equipment are an integral part of the x-ray safety program; inspections provide some indication as to whether or not the x-ray sources are being operated in a safe manner. Principal Investigators are encouraged to conduct regular safety inspections of the equipment. An x-ray safety checklist can be found in Appendix 2. The RSO is responsible for inspecting all new x-ray equipment as well as an annual audit of all existing x-ray machines. The Principal Investigator will be informed of the audit results and of any necessary measures required to improve the safety of the x-ray equipment. 4.5 X-RAY SIGNS AND WARNING SIGNALS The outside of each room containing x-ray equipment will be affixed with the appropriate x-ray warning sign (provided by the RSO). The sign must be clearly legible and visible at a distance of 2 meters to individuals approaching the room door. November 2009 10

Each piece of x-ray equipment must have the appropriate signs indicating that x-rays are being produced, as per the Radiation Emitting Devices Act. The control panel of each piece of equipment must indicate when the machine is producing x-rays. A warning light shall be mounted near each x-ray tube in such a way as to be clearly visible from any direction, which indicates when x-rays are being produced. 4.6 LABORATORY SECURITY Safeguarding University resources from unauthorized access, misuse or removal is a responsibility of all faculty and staff. At a minimum, the university expects all laboratory personnel to comply with the following procedures: All laboratories must be locked when not occupies Report all suspicious activity immediately to Campus Security by calling 250-721-7599 4.7 TRAINING Prior to an individual operating or working in close proximity to any piece of analytical x-ray equipment the individual must participate in the University s X-ray Safety Training Program. The program is comprised of two components: general training and job specific training. The RSO provides the general training that includes: basic theory, radiation interactions, biological and health effects, radiation detection and measurement, and a review of federal and provincial regulations and UVic policies and procedures for working with x-rays. The principal investigator is responsible for notifying the RSO when an individual requires general training prior to their starting work with x-ray equipment. It is the principal investigators responsibility to provide training specific to the equipment and research, and to keep training records. November 2009 11

4.8 DOSIMETERS When required to do so by the Radiation Safety Officer, individuals working with or within the vicinity of an X-ray source shall wear a personal dosimeter. The RSO will verify that the dose recorded by the personal dosimeter is reasonable and appropriate in the circumstances and will notify the individual, Principal Investigator and the Radiation Safety Committee of any dose that does not seem reasonable. The RSO will retain the personal dosimeter records for a period of at least 3 years. The National Dose Registry of Health Canada keeps the life time exposure records. 4.9 EXPOSURE LIMITS All University employees and students working with radioactive sources in research or teaching areas are considered members of the public, and as such are held to the same exposure limits. Table 1: Maximum Permissible Dose Equivalent Per Year Maximum permissible dose equivalent Limits per year Body organ or tissue Radiation Worker Member of the public Whole body 20 msv 1 msv Lens of the eye 150 msv 15 msv Skin (1 cm2) 500 msv 50 msv All organs 500 msv ACTION LEVELS A. If quarterly, effective whole-body or extremity dose readings from dosimeters exceed 0.2 msv for researchers or staff the RSO will: 1. Initiate an investigation to determine the cause 2. Make recommendations to help minimize future doses related to the type of activity or research that led to the exposure November 2009 12

4.10 SURVEY METERS All locations where x-ray equipment is used will have an appropriate survey meter to: Identify and monitor radiation levels at critical areas (tube housing, beam ports, shutters, analysis accessories, etc.) of the equipment during set up and beam alignment procedures, and following modifications and alterations to the device or its accessories, Ensure that compliance with the regulatory limit (5 µsv per hour at 5 cm from any external surface of the equipment) is maintained, and that the permissible dose limits would not be exceeded under routine operation conditions of the equipment. 4.11 PREGNANT PERSONNEL A pregnant personnel has the opportunity to discuss with the Radiation Safety Officer her dosimetry history, work schedule, and workload, as well as the risks associated with the use of ionizing radiation during pregnancy. It shall be the choice of the worker to determine whether she shall continue to work with x-ray sources. 4.12 ACCIDENTS & EMERGENCIES i. In the event of an emergency after hours or during the weekend, Campus Security Services is to be notified immediately at local 7599. ii. In those instances where any person is suspected to have received or is likely to have received a radiation exposure, the Radiation Safety Officer is to be informed immediately. 4.13 COMPLIANCE & ENFORCEMENT Failure to comply with provincial and federal regulations and or university policies and procedures may result in registration certificate cancellation and suspension of work activities, to be subject to review by the Radiation Safety Committee. November 2009 13

6.0 RESOURCES Health Canada, Safety Code 32: http://www.hc-sc.gc.ca/ewh-semt/pubs/radiation/94ehd-dhm186/index-eng.php Radiation Emitting Devices Act: http://laws.justice.gc.ca/en/showtdm/cs/r-1//20090725/en Radiation Emitting Devices Regulations: http://laws.justice.gc.ca/en/r-1/c.r.c.-c.1370/index.html WorkSafe BC: http://www2.worksafebc.com/publications/ohsregulation/part7.asp November 2009 14

APPENDIX 1 X-RAY EQUIPMENT REGISTRATION FORM Instructions 1. Complete and sign the registration form. 2. Send the completed form to the Department of Occupational Health, Safety & Environment. 3. After verification of your registration form a date will be arranged for inspection of the equipment. 4. Following inspection of the equipment, you will then receive a compliance verification report. 5. If there are any item(s) of noncompliance identified they must be corrected. 6. Written verification of corrective action must be provided to the RSO. 7. Upon review by the Radiation Safety Committee a Registration Certificate will be issued. 8. If you have any questions on how to complete the registration form or a question concerning the registration process contact the Radiation Safety Officer at 721-8876.

Form 1A X- Ray Equipment Registration Occupational Health, Safety and Environment UNIVERSITY OF VICTORIA PO BOX 1700 STN CSC VICTORIA BC CANADA V8W 2Y2 TELEPHONE (250) 721-8971 FAX (250) 721-6359 EMAIL: ohs@uvic.ca WEB: www.ohs.uvic.ca Part 1: General Information X-Ray Equipment Registration A. Reason for Application Equipment: New Facility: New Renewal Renewal Modification Modification Relocation B. Equipment Owner Information Name: Office: Phone: E-mail: C. Type of Facility Research Education Medical Other specify: D. Type of Equipment X-Ray: Radiographic Fluoroscopic Cabinet Diffraction Other specify: Revised: October 2, 2009 1

Form 1A X- Ray Equipment Registration E. Designated Equipment Description Installation: Stationary Mobile Portable Manufacturer: Model: Serial No: Date: Tag No: Location: Characteristics of equipment: Maximum rated tube voltage is: kilovolts; Maximum rated tube current is: milliamperes; Anticipated maximum workload is: ma/min per week F. Proposed Use(s): (Please attach additional pages if needed) Part 2: Personnel (Principal Investigator and X-Ray Users) Surname Given Name Gender m/f Job Title X-Ray Safety Training Year Place Revised: October 2, 2009 2

Form 1A X- Ray Equipment Registration Part 3: Facility (This section is required only for sources containing x-ray beams that are not fully enclosed.) Please provide the composition of all walls in the location that will house the x- ray equipment: Floor: Ceiling: Walls: North East South West For each of the following directions, please provide the occupancy type, occupancy percent and the usage factor: Occupancy type the nature of the use of the area (e.g. lab, washrooms, hallway, storage area, waiting room, etc.) Occupancy percent as a percentage, the time the area will be occupied while the x-ray equipment is operational. Usage factor the fraction of time the beam will be pointed in the direction a percentage of the total time the x-ray equipment is operational. Down Up North East South West Direction Type Occupancy Percent Usage Factor (percent) Revised: October 2, 2009 3

Form 1A X- Ray Equipment Registration Part 4: Signatures Applicant Signature Date Department Head Signature Date Radiation Safety Officer Date Radiation Safety Committee (Chair) Date Revised: October 2, 2009 4

APPENDIX 2 X-RAY EQUIPMENT SAFETY AUDIT Notes 1. Principal Investigators are encouraged to use this form when conducting safety audits. 2. X-ray equipment safety audits should be performed periodically. 3. Keep a record of the safety audit for a minimum of three years.

Form 2A X- Ray Equipment Safety Audit Occupational Health, Safety and Environment UNIVERSITY OF VICTORIA PO BOX 1700 STN CSC VICTORIA BC CANADA V8W 2Y2 TELEPHONE (250) 721-8971 FAX (250) 721-6359 EMAIL: ohs@uvic.ca WEB: www.ohs.uvic.ca X-Ray Equipment Safety Audit Principal Investigator: Registration #: Building: Room Number: Date: PERSONNEL / ADMINISTRATIVE YES NO N/A COMMENTS 1. X- ray workers/supervisors are trained? 2. Policies and Procedures Manual present? 3. Dosimeters worn? 4. Dosimeters stored away from active areas? 5. Personal protective equipment available and worn if necessary? SECURITY YES NO N/A COMMENTS 6. Access to x- ray sources is controlled? 7. When laboratory is unattended, entrance doors are locked? 8. Unattended x- ray sources are locked? SIGNAGE YES NO N/A COMMENTS 9. Current registration form is posted? 10. Room x- ray sign posted with emergency contact numbers? 11. X- ray source sign posted? MONITORING YES NO N/A COMMENTS 12. X- ray sources inspected by the x- ray supervisor periodically? Revised: June 5, 2009 1

Form 2A X- Ray Equipment Safety Audit 13. X- ray source leakage checked? 14. Ambient radiation less then 5 µsv/hr at 5 cm from all external surfaces? 15. Records kept for 3 years? ENGINEERING CONTROLS YES NO N/A COMMENTS 16. Appropriate shielding is available? 17. X- ray machine key control used? 18. X- ray tube ON light functional? 19. ON/OFF x- ray tube energized sign on control panel functional? 20. Diaphragms, cones or collimators are provided if necessary? 21. Primary beam terminated? 22. Cabinet/shield/sample interlocks have been installed? 23. Interlocks are functional? 24. Unused port flap shutter installed? SURVEY METER YES NO N/A COMMENTS 25. Calibrated survey meter available? 26. Instrument functioning properly? Battery, Audio, and test source? Survey Meter: Make: Meter (serial #): Detector (serial #): Date of last Calibration: Other comments: Auditor Name: Date: Revised: June 5, 2009 2

APPENDIX 3 SAFETY CODE 32: PRE-OPERATIONAL SAFETY CHECKS

Health Canada Safety Code 32 Excerpt Pre-operational Safety Checks When analytical x-ray equipment is installed and whenever maintenance functions are preformed on it or on its accessory components, the user must conduct examinations or tests that ensure: (i) (ii) (iii) (iv) the proper functioning of all protective and safety devices; the proper assembly and functioning of all radiation shields, beam ports, accessories and fittings; the ambient radiation levels are within the permissible regulatory limit (5 µsv per hour at 5 cm from all the externals surfaces of the equipment) by using an appropriate survey meter; and any safety by-pass procedures are of the one time actuation and revert back to a fail-safe situation at start-up time of the x-ray generator. 1