Purpose

The purpose of this procedure is to ensure a prompt and appropriate response in the event of an accident or incident involving a radiation source, as well as to ensure that radiation protection work at NTNU complies with regulatory requirements and safeguards the safety of employees, students, and others at NTNU.

Scope and anchoring

This procedure applies to all units, employees, and students at units that use radiation sources owned by NTNU. The procedure is a measure to reduce the risk associated with work involving radiation sources.

The Guideline for radiation protection and use of radiation sources forms the governing basis for this procedure.

Responsibility

The line manager is responsible for ensuring that the procedure is made known and complied with within their unit.

Definition of an accident or incident involving a radiation source

According to section 20 of the Radiation protection regulations, the following are considered accidents, incidents, or abnormal events:

• Events that cause or could have caused unintended exposure of workers, patients, or other individuals significantly beyond normal levels, or unexpected radiation injuries
• Loss, theft, or sabotage of radiation sources
• Unintended release of radioactive substances into the environment
• Events that may lead to exposure of the general public such that an individual could receive more than 0.25 mSv/year
• Technical failures with radiation protection relevance
• Significant deviation from the intended absorbed dose or activity delivered to exposed tissue in patients
• Severe radioactive contamination of the facility’s premises or equipment
• Discovery of abandoned radiation sources

Fire in a room containing radioactive sources is also considered a possible incident

All events described in section 20 of the Radiation Protection Regulations must be reported to the Norwegian Radiation and Nuclear Safety Authority

Procedure for emergency preparedness and response in the event of an accident or incident involving a radiation source

Initial response

Initial response to acute injuries caused by X-rays, lasers, or UVC radiation

• Turn off the source and assess the extent of the injuries.
• Call 113 (emergency services) in case of acute need for medical assistance.
• In the event of serious eye injuries:

1. Call the ophthalmology department at St. Olavs Hospital directly, telephone 06800.
2. The injured person must be accompanied to the hospital by another employee, preferably someone familiar with the radiation source involved.

• Be aware that a latency period may occur for all types of injuries caused by these forms of radiation. If there is any doubt as to whether an injury has occurred, consult a physician/ophthalmologist.
• Notify the room responsible/instrument custodian and the local radiation protection coordinator.

Initial response to an accident/incident involving radioactive radiation

• Focus the initial response on securing the area that may be contaminated.
• Evacuate and seal off the room in the event of a spill or ventilation failure.
• Notify the room responsible/instrument custodian and the local radiation protection coordinator.
• The response at the scene shall be led by the room responsible person, instrument custodian, or local radiation protection coordinator, in accordance with the guidelines applicable to the specific radioactive source.
• Wear appropriate protective equipment when removing spills. Check radiation levels before and after cleanup.
• In case of ventilation failure, personnel with radiation protection competence and appropriate measurement equipment should assist technical staff.
• Register all individuals who have been exposed.

Tasks – Room responsible person / Instrument custodian

In the event of an incident involving the risk of dispersion of radioactive material

Notify the following:

1. Immediate supervisor and head of department
2. Local radiation protection coordinator
3. Central radiation protection coordinator, phone: +47 91 87 78 56. If outside regular working hours, call NTNU's emergency phone: 800 80 388 to reach the coordinator.
4. Norwegian Radiation and Nuclear Safety Authority (DSA), phone: +47 67 16 25 00, must be notified if the central radiation protection coordinator is unavailable.
5. Building manager (if cleaning or technical staff need to take special precautions)
6. Local chief safety representative

In the event of loss or theft of radiation sources

Notify the following:

1. Immediate supervisor and head of department
2. Police, phone: 02800
3. Local radiation protection coordinator
4. Central radiation protection coordinator, phone: +47 91 87 78 56. If outside regular working hours, call NTNU's emergency phone: 800 80 388.
5. Norwegian Radiation and Nuclear Safety Authority (DSA), phone: +47 67 16 25 00, must be notified if the central radiation protection coordinator is unavailable.

In the event of serious personal injury (laser, X-ray, UVC)

1. Notify in accordance with the central emergency response plan, DFU 01: Missing/Injured/Deceased – Student, Employee or Visitor.
2. Also notify:
3. Local radiation protection coordinator
4. Central radiation protection coordinator, phone: +47 91 87 78 56. If outside regular working hours, call NTNU's emergency phone: 800 80 388.
5. Norwegian Radiation and Nuclear Safety Authority (DSA), phone: +47 67 16 25 00, must be notified if the central radiation protection coordinator is unavailable.

For further information, the following may be contacted:

• Supplier of the radiation source/device/instrument
• Institute for Energy Technology (IFE) for assistance with analysis and handling

Follow-up

• Report the incident as a deviation
• Prepare and send a report to the Norwegian Radiation and Nuclear Safety Authority (DSA)

Tasks – Local radiation protection coordinator

• Assist the room responsible person/instrument custodian in radiation-related incidents.
• Conduct a rapid risk assessment of the situation. Evaluate the need for room isolation, use of protective equipment, notification of technical personnel, etc.
• Assume responsibility for handling the incident if the room/instrument responsible person lacks sufficient competence or is not present.
• Assist the instrument/room responsible person with reporting to the Norwegian Radiation and Nuclear Safety Authority (DSA).

Follow-up

• Ensure that the report is submitted to DSA within 3 days.
• Follow up on non-conformities and actions identified in the report to DSA.
• Follow up on students and employees exposed to unintended radiation, including registration in the exposure index (Regulation on the performance of work section 31-4).
• Conduct an evaluation after the incident.
• Review and update local procedures.

Tasks – Central radiation protection coordinator

• Assist the local radiation protection coordinator and emergency management (local and, if necessary, central) with expert knowledge.
• Consult external professional expertise, such as DSA.
• Report the incident to the Head of Health, Safety and Environment (HSE).
• Participate in evaluation meetings to ensure lessons are learned from the undesired incident.
• Share lessons learned with local radiation protection coordinators.
• Update information in central guidelines.

Reporting

Reporting to the Norwegian Radiation and Nuclear Safety Authority (DSA)

• Notify verbally immediately after the incident.
• Submit a written report within three (3) days after the incident. In cases of uncertainty about whether the incident should be reported, contact the central radiation protection coordinator or DSA by phone.
• The report shall be prepared by the instrument custodian/room responsible person in collaboration with the local radiation protection coordinator and, if relevant, other individuals involved in the incident (e.g., technical responsible person, operations staff, laboratory technicians, etc.).
• The report shall be submitted to the central radiation protection coordinator, who will forward it to DSA. Alternatively, it may be sent directly to DSA, with a copy to the central radiation protection coordinator.

The report must at a minimum contain:

• Name and address of the institution where the incident occurred
• Assigned approval number and/or notification number for the institution
• Information on who prepared the report
• Names of all individuals involved
• Time and location of the incident, i.e., where within the institution it occurred
• Description of the sequence of events
• Measures taken/to be taken to resolve the situation
• Calculated/estimated radiation doses received by the individuals involved
• Preventive measures, i.e., actions that can prevent or reduce the risk of similar incidents

For incidents involving open radioactive sources, the report must also include:

• Calculation/estimate of internal and external radiation doses
• Information about the type of radioactive material and the amount of activity involved
• Estimate of any release of radioactive substances into the environment

Information for area/building responsible personnel

• If evacuation is necessary, it shall be carried out in accordance with the local emergency response plan/local evacuation plan, and, if applicable, in consultation with the fire department.
• The quantity and strength of radioactive sources used at NTNU are not such that emergency responders should be prevented from entering the area.
• However, entering a room where lasers are in use without proper protection may pose a risk.