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Chapter 12 - Violation Policy

12. Cornell University Radiation Safety Violation Policy (Top)

 

12.0 Radiation Safety Violation Policy (Top)

Every individual using ionizing radiation must abide by the applicable requirements of the Cornell Radiation Safety Manual and the conditions of the permit or registration issued by the RSC authorizing that use. In addition, the permit holder or registrant supervising the individual is responsible for the actions of the individual. The RSO is authorized by the RSC to respond to violations of these requirements and conditions as described below.
 
Violations are acts and omissions contrary to the Cornell radiation safety program. Accidents, even serious accidents, are not in themselves violations. Activities carried out in good faith compliance with the expectations of the radiation safety program will not be considered violations. 
 
 
The primary consideration in the use of ionizing radiation at Cornell University must be to prevent excessive exposure of personnel to contamination and external radiation. The following examples are considered imminent health hazards.  

 

12.1.1 extensive laboratory contamination

12.1.2 loss of significant quantities of radioactive material

12.1.3 excessive radiation fields in unrestricted areas

12.1.4 unsecured high health hazard radioactive stock material 

If, in the opinion of the RSO, a violation creates an imminent hazard to human health, the RSO will take immediate and appropriate action to eliminate or control the hazard and will suspend further use of the material or equipment. Such action may include barring access to areas, removing radioactive material from a laboratory or locking out the power supplies to radiation producing equipment.
 
The suspension will remain in effect until the situation has been reviewed by the RSO and RSC. If warranted, an individual's authorization to use radiation sources and/or the permit or registration will be terminated. If termination is not warranted, the permit or registration may be suspended for an extended period and appropriate new conditions may be added to the permit or registration to prevent recurrence of the violation. 
 
Every worker and supervisor has the responsibility to report to the RSO as soon as possible any situation that may pose an imminent health hazard and to assist the RSO with the evaluation and control of the situation. 
 

The RSO will respond to violations that do not pose an imminent hazard to health with an initial emphasis on education about the issue and suggestions for corrective action. This category includes: 
 

 

12.2.1 failure to train and supervise workers

12.2.2 use of radiation sources by unauthorized individuals

12.2.3 failure to wear personal protective clothing

12.2.4 unauthorized experimental procedures

12.2.5 failure to perform radiation protection surveys

12.2.6 survey or monitoring equipment unavailable or not operational

12.2.7 elimination or bypassing of safety interlocks

12.2.8 unsecured low health hazard radioactive stock material 

First time violations will be brought to the attention of the Permit Holder or Registrant, in writing, by the EH&S staff member discovering the violation. The Permit Holder or Registrant must respond to the notification in writing to indicate that the violation has been corrected, describe the corrective action taken, and specify how future occurrences will be prevented. 
In some cases, the EH&S staff member may require on going confirmation that the violation has been corrected. For example, for a failure to maintain adequate radiation protection survey records, the Permit Holder may be required to submit duplicate copies of the records to the staff member for several months.
 
For repeat violations, the RSO will require implementation of more rigorous procedures and greater personal supervision by the Permit Holder or Registrant. A violation from this category, one that may directly influence the radiation exposure of an individual, will be considered a "repeat violation" if it occurs twice within two years (5 consecutive inspections).
 
 
Other violations will be considered repeat violations if they occur twice within one year (three consecutive inspections). Examples of these violations include the following:  

 

12.3.1 inadequate radiation protection surveys

    12.3.2 inadequate radioactive material inventory and disposal records
    12.3.3 inadequate labeling of work areas, containers and storage areas  
The RSO will bring a repeated violation to the attention of the Permit Holder and Department Head and will require a written response and/or actions that demonstrate that:  
 
1) current violations have been corrected and  
 
2) the Permit Holder understands how to avoid repeating the violation in the future.
The RSO may impose temporary restrictions on operations, require the development and implementation of new procedures or require the attendance of the individual, Permit Holder or Registrant at training and retraining programs presented by EH&S. 
 
When repeat violations continue to occur, the RSO will take the action deemed appropriate to obtain compliance, including modification, extended suspension or termination of the permit or registration. The RSO will advise both the Permit Holder or Registrant (and/or individual) and the Chair of the RSC of such action. The Permit Holder or Registrant (and/or individual) may request the RSC to review this action and consider alternate action. 
 
Violation Policy Attachment I - 03/15 
Examples of Violations 
 
Actions taken by the RSO in response to violations will vary according to the consequences, or potential consequences, of the violation and the past compliance history of the Permit Holder or Registrant. The following examples illustrate how this policy will be applied to several typical violations.

Example 1:  Failure to maintain proper survey records per Chapter 5 sec. 5.6 of the Radiation Safety Manual. 
 
“Areas (e.g., hoods, bench tops) in which radioactive materials are being used should be checked for contamination as soon as each procedure is completed by the radiation workers in that laboratory. These areas must be inspected each and every time there is reason to suspect contamination. Monthly wipe and instrument surveys must be conducted with recorded positive and negative survey results in the Permit Holders’ laboratory logs.” 
 
1st violation: Memo from Permit Holder indicating that deficiencies in survey procedures and/or reports have been corrected and will not be repeated (current month's survey report attached to memo for review by EH&S). Copy of monthly survey reports sent to EH&S each of the next three months.
 
2nd violation: Permit holder required to attend retraining program on radiation protection surveys at EH&S. 
 
3rd violation: Authorization to purchase radioactive material suspended for 30 days and/or stock radioactive material impounded for 30 days. Also require copies of monthly survey reports mailed to EH&S for each of the next six months. 
 
Example 2:  Failure to provide monthly inventory report per Chapter 2 sec 2.4.5.3 of the Radiation Safety Manual. 
 
"... records indicating the receipt, dispensation, transfer and disposal of radioactive materials. An end of month inventory of radioactive materials must be reported to the EH&S..."
 
1st violation: Five day extension to provide report to EH&S.
 
2nd violation: Suspend purchase of radioactive material and/or impound stock material until summary is provided
 
3rd violation: Suspend purchase of radioactive material 30 days and/or impound stock material for 30 days. 
 
Example 3:  Unauthorized transfer of radioactive material per Chapter 9 of the Radiation Safety Manual.
 
"Transfer of materials between Permit Holders is sometimes permissible, but only with prior approval by the R S O." 
 
1st violation: Memo from Permit Holder describing the isotope, activity and recipient involved in the transfer and indicating that unauthorized transfers will not be made in the future. 
 
2nd violation: Permit holder required to develop detailed written procedure for transfer of radioactive material from the laboratory and to train laboratory staff to follow them. 
 
3rd violation: Suspend purchase of radioactive material 30 days and/or impound stock material for 30 days. 
 
Example 4:  Failure to provide adequate instruction to workers per Chapter 2 sec 2.4.3 of the Radiation Safety Manual. 
 
"Ensuring that all individuals working in a restricted area have been instructed in the following: 
    1. Procedures and precautions to minimize exposure
    2. Purpose and function of protective devices
    3. Reporting requirements (Ch. 11)
    4. Responses to emergencies or malfunctions (Ch. 10)
    5. Availability or radiation exposure reports
    6. Health protection problems associated with radiation exposure
The extent of these instructions must be commensurate with potential radiological health protection problems."

1st violation: Memo from the Permit Holder or Registrant indicating that his or her responsibilities for instruction have been made clear and indicating the date by which all individuals working in restricted areas will have received this instruction.

2nd violation: Permit Holder or Registrant required to develop written training outline of topics and procedures relevant to radiation safety in the laboratory. The Permit Holder or Registrant required confirming that this information has been presented to all individuals working in restricted areas.

3rd violation: Suspend purchase of radioactive materials 30 days and/or impound stock material for 30 days. 
 
Example 5:  Failure to provide or maintain appropriate monitoring or survey equipment per Chapter 2 sec. 2.4.5.7 of the Radiation Safety Manual.
"Making available the appropriate apparel, shielding and monitoring equipment to assure minimal exposure and contamination."

1st violation: Memo from Permit Holder or Registrant indicating that the requirements for monitoring and survey equipment are understood and have been met.

2nd violation: Permit Holder or Registrant required to attend retraining program on radiation protection surveys at EH&S.

3rd violation: Authorization to purchase radioactive material suspected for 30 days and/or stock radioactive material impounded for 30 days or authorization to use radiation producing equipment suspended for 30 days. Permit Holders also are required to mail copies of monthly survey reports to EH&S for each of the next six months. 
 
Example 6:  Failure of worker to wear appropriate protective clothing per Chapter 2 sec 2.5.3.1 of the Radiation Safety Manual.
'Wearing a lab coat and disposable gloves at a minimum whenever contamination is possible, and not wearing such articles outside of the laboratory area."

1st violation: Memo from Permit Holder indicating that the policy in the laboratory requires users to wear protective clothing whenever they are handling radioactive material.

2nd violation: Permit holder required to develop detailed written procedure for handling radioactive material in the laboratory, to train laboratory staff to follow them, and to post the procedures in every authorized isotope use room.

3rd violation: Suspend purchase of radioactive material 30 days and/or impound stock material for 30 days.