Purpose

The purpose of this guideline is to ensure that all use of radiation sources at NTNU complies with governmental regulations and safeguards the safety of employees, students, and others at NTNU.

Scope and foundation

All use of radiation must be justified, meaning that its use must be necessary and lead to the lowest possible doses and minimal exposure to the surroundings, as far as is practically achievable.

This guideline is part of NTNU’s governing regulations and applies to all employees. The HSE policy governs this guideline. Associated procedures describe the practical steps for implementation.

Responsibilities

Line Managers ensure that the guideline and associated procedures are known and followed within their unit.

Definition

Radiation sources are divided into two main categories:

• Ionizing: Radioactive materials, X-ray machines, electron microscopes
• Non-ionizing: For example lasers, shortwave ultraviolet radiation (UVC), sources with potentially harmful electromagnetic radiation

Organization and implementation

Rector

Must:

• Appoint a central radiation protection coordinator. At NTNU, this coordinator is placed within the HSE section.

Central radiation protection coordinator

Must:

• Administer and coordinate NTNU’s systematic radiation protection work
• Stay updated on relevant laws, regulations, and local policies governing radiation sources at NTNU
• Ensure NTNU holds necessary approvals in accordance with Radiation Protection Regulations, section 9
• Serve as a liaison between NTNU and the Norwegian radiation and nuclear safety authority (DSA)
• Report to the HSE Manager
• Assist units with:
  • Guidance on safe use of radiation sources and protective equipment
  • Determining (measuring, estimating) radiation exposure and doses
  • Risk assessment of activities involving radiation
  • Guidance on disposal of radiation sources and decontamination
  • Evaluation of exposure and potential health risks

Line manager

Must:

• Ensure that all radiation use complies with laws and regulations
• Appoint one or more local radiation protection coordinators (LRPCs) before starting radiation work, or take on the role themselves
• Ensure local protection coordinators have adequate competence, time, and resources
• Ensure all users of radiation sources have adequate training
• Assess whether it is necessary to establish a local emergency preparedness plan for accidents, incidents, and abnormal events involving radiation sources. The local emergency plan must be aligned with the central and site-specific emergency plans, DFU10 Accidents and Incidents Involving Radiation Sources. It is important that the emergency plan is communicated within the organization.
• Ensure that local guidelines, procedures, and/or instructions for the use and disposal of radiation sources are in place where necessary. This includes routines that ensure radiation sources are disposed of as soon as possible after their use has ended.
• Ensure risk assessments are conducted
• Classify occupationally exposed employees as per section31 of the Radiation Protection Regulations
• Ensure that employees undergo targeted health examinations in accordance with the requirements set out in the Regulation on the Performance of Work sections 15-4 (ionizing radiation), 16-7 (artificial optical radiation), and 16A-7 (electromagnetic fields). See also NTNU’s internal regulations.
• Ensure that a register is kept of employees working with ionizing radiation, in accordance with section 31-4 of the Regulation on the Performance of Work.
• Follow checklist for new acquisitions involving high-risk devices (laser class 4, X-ray machines, etc.)
• If the unit’s employees use radiation sources in the same premises as other organizations, the line manager must ensure that coordination agreements are established to clarify HSE responsibilities.

Local radiation protection coordinator

Must:

• Administer local radiation protection activities
• Have knowledge about and offer guidance on exposure assessment, spill/contamination management, source disposal, etc.
• Assist with risk assessments, training, and safety measures
• Maintain an overview of:
  • All radiation sources at the unit; purchase, use, storage, and disposal. Information about location, source type, and temporary transfers must also be recorded. The lists shall be maintained continuously for each individual laboratory or research group. Any serial numbers or other information that can uniquely identify the sources shall be registered.
  • All users of radiation sources at the unit, their qualifications, and the category of occupationally exposed workers to which they belong (in accordance with section 31 of the radiation protection regulations). See the overview template (docx). Occupationally exposed persons are defined as all employees exposed to radiation as part of their work, where the radiation source or exposure situation is a foreseeable and inherent part of their occupational activity. In the NTNU context, this also includes master’s students and doctoral candidates who handle radiation sources, either independently or in collaboration with others (e.g., supervisors).
  • Discharges and disposal of radioactive materials
  • Applicable legislation and internal regulations
• Ensure the registration of notifiable sources, pursuant to section 13 of the Radiation Protection Regulation via DSA’s electronic system
• Notify the central coordinator if approvals other than the general ones that NTNU have are required
• Annually report the overview of the purchase, use, storage, and disposal of radiation sources to the central radiation protection coordinator.
• Notify the central radiation protection coordinator of all users who may risk exposure to radiation doses exceeding 1 mSv per year from ionising radiation sources.
• Ensure that radiation sources, equipment, and all rooms where radiation sources are used and stored are properly labeled in accordance with regulations and secured against theft, sabotage, and damage caused by, for example, fire and water.
• Ensure the proper disposal of radiation sources that are no longer in use
• Ensure that the use of radiation sources is in compliance with legislation and any applicable local regulations
• Perform or organize routine contamination checks as needed
• Ensure that all accidents and unwanted incidents are reported as deviations.
• Report to the Line Manager

Academic supervisor

Refers to individuals who have the task of leading or supervising other employees or students in work conducted in laboratories, workshops, or field settings. This may, for example, be a scientific supervisor for a doctoral or student project, a project leader, or the head of a professional group or laboratory.

Must:

• Acquire necessary information about radiation sources
• Familiarize oneself with central and local guidelines, manuals, the use of measurement and protective equipment, waste management, as well as local emergency plans related to work with relevant radiation sources
• Notify the local radiation protection coordinator regarding all aspects of radiation sources and their usage, including acquisition, placement, relocation, disposal, any potential emissions, and other relevant activities.
• Collaborate with local radiation protection coordinator on operating procedures and emergency actions
• Conduct risk assessments related to work with radiation sources, including the implementation of necessary measures.
• Authorize users, ensure that users of radiation sources possess the appropriate competence, and define access to equipment and rooms containing radiation sources.
• Monitor safe storage and safety equipment functionality
• Ensure that waste from work with radiation sources is stored and disposed of in accordance with the procedure for the disposal of radioactive waste
• Inform all personnel associated with the premises (such as safety representatives, room managers, and maintenance staff) about the work involving radiation sources and the necessary precautions to be taken
• Assess necessary measures, safety equipment, and safety functions. Evaluate suitable equipment for performing control measurements of radiation sources
• Ensure hazard labeling, access control, and the implementation of measures to prevent theft, sabotage, fire damage, water damage, and similar risks for sources, equipment, and workplaces (including entire rooms or parts thereof)
• Ensure that work activities are systematically organized and conducted in accordance with applicable regulations and best practices to minimize radiation exposure to personnel.

Instrument custodian

For some radiation sources it may be necessary to appoint an employee that is responsible for the instrument that contains the radiation source.

Must:

• Register new acquisitions, relocation, and disposal of radiation sources with the professionally responsible person and the local radiation protection coordinator.
• Perform or organize necessary maintenance and servicing of radiation sources in accordance with established protocols. Service activities may be conducted by operations personnel or technical staff only after obtaining prior authorization from the designated instrument custodian.
• Provide user training on radiation sources.
• Maintain a logbook
• Establish and maintain an information binder for radiation sources.
• Provide an update operating instructions, equipment log, and list of authorized users for each instrument.
• Ensure correct labeling and signage
• Ensure Physical security of radiation source(s) as required
• Assess the risks associated with various types of service work and minor modifications typically performed on the instruments, and implement internal procedures for monitoring potential leakage radiation.

Authorized user

Must:

• Complete required training
• Understand applicable procedures
• Log usage as required (e.g., in logbook for non-ionizing sources)
• Perform contamination checks on the workspace and self when required (e.g. after working with open radioactive sources)

Training

All users working with radiation sources must, at a minimum, possess knowledge equivalent to the learning outcomes described in the courses offered through the Learning Portal. In addition, all users must receive local training tailored to the specific radiation source to be used. Adequate training must be completed prior to commencing work and may include a general approach to radiation protection. The training shall cover internal procedures, instructions, risk factors, protective and measurement equipment, waste management, and incident reporting.

After completing training and before working with radiation sources, the user must at minimum be familiar with:

• Regulations for the specific radiation source
• Responsibilities and tasks of the line manager and the academic supervisor within radiation protection. One should also be familiar with the responsibilities and tasks of the central and local radiation protection coordinators.
• All changes in the use of radiation sources, including the acquisition of new sources, identification of damaged sources, or initiation of new projects must be promptly reported to the academic supervisor or the local radiation protection coordinator in accordance with established communication protocols
• Emergency procedures for the relevant radiation source.
• Responsibility for ensuring that work is conducted in a manner that keeps radiation exposure to a minimum and does not pose a risk to one's own health, the health and safety of others, or the external environment.
   
• Responsibility for reporting any undesirable incidents or deviations (non-conformities).
• All activities involving radiation sources must be documented in accordance with regulatory and institutional requirements. E.g., the use of non-ionising radiation sources shall be recorded in a designated logbook, which must be stored at the site of the radiation source.
• How to perform contamination monitoring in the workplace—and, as far as practically possible, on oneself—when required by regulations (for example, after working with open radioactive sources).

Permanent staff, PhD candidates, project employees, or students who regularly use radiation sources must complete an introductory course and a user course, including passing the course examination. In this context, 'regularly' is defined as monthly or more frequently.

Permanent staff, PhD candidates, project employees, students, and guests who use radiation sources for a short period must complete an introductory course in radiation protection

All individuals who enter or have access to areas where radiation sources are in use,regardless of whether they operate the sources themselves,must receive appropriate radiation safety training corresponding to the level of potential exposure.

Completed training must be documented.

Risk assessment

Before any work involving radiation sources is initiated, a risk assessment must be carried out. Documentation of the completed risk assessment must be retained in accordance with the Radiation Protection Regulations and the Internal Control Regulations

Example of questions to ask during an HSE (Health, Safety, and Environment) inspection round:

• How does the unit ensure compliance with radiation protection requirements?
• Does the unit need to improve its routines?
• How does the unit work to minimize potential exposure of personnel and adjacent areas to the unit’s radiation sources?
• How does the unit work to reduce the use of ionizing radiation sources, or alternatively transition to ionizing sources with lower activity?
• How are environmental discharges prevented?

Physical security of radiation sources

Possible measures for the physical security of radiation sources include:

• Radiation sources are stored in rooms with access control, such as card locks or other systems that ensure the door is always locked when unattended.
• The number of individuals with access to rooms where radiation sources are stored is limited to a minimum.
• Waste storage rooms for radiation sources have access control, such as card locks or other systems ensuring the door is always locked.
• Waste storage rooms for radiation sources are equipped with specialized doors.
• Radioactive sources are used in immediate proximity to their storage location and only within designated specialized rooms.
• Information about the quantity, isotope type, and storage location of radiation sources are kept confidential and exempt from public disclosure.
• Storage locations for radiation sources are discreetly marked.
• Radioactive sources are stored in locked storage cabinets or safes.
• Storage cabinets/safes are fixed to the wall and cannot be removed without opening.
• Storage cabinets/safes are large, heavy, and difficult to transport.
• Regular inspections are conducted on radioactive sources stored in cabinets/safes.
• Continuous supervision is maintained when radioactive sources are removed from storage cabinets/safes.
• Radioactive sources and related waste are stored in waterproof packaging.
• Employees and students receive training on proper storage and handling of radiation sources.
• Written procedures exist for packaging and notification in connection with the transport of radioactive sources from one usage site to another.

Targeted health examinations

Employees who work with radiation sources shall undergo targeted health examinations if:

• Exposure >6 mSv/year
• Exposure may result in an equivalent dose per year exceeding 3/10 of the dose limits specified in section 30 of the Radiation Protection Regulations (see section 15-4 of the Regulations on Work Execution).
• Exposure to artificial optical radiation exceeds the limit values specified in section 4-2 of the Regulations on Action and Limit Values (see section 16-7 of the Regulations on Work Execution).
• You have a disease caused by exposure to artificial optical radiation.
• Exposure to electromagnetic fields exceeds the limit values specified in section 4-3 of the Regulations on Action and Limit Values
• You have a diagnosed condition caused by exposure to electromagnetic fields.
• The risk assessment indicates that there is a health risk for you during work with radiation sources.

The health examination will determine whether there are medical reasons that prevent you from working with ionizing radiation/non-ionizing sources, or whether special measures are necessary. You can read more about targeted health examinations here

Pregnant employees

Anyone who is pregnant or planning to become pregnant must promptly inform their line manager, academic supervisor, and/or local radiation protection coordinator so that necessary measures can be implemented.

More information can be found here: Pregnant Workers and Radiation.

Reporting

Radiation source acquisition

When purchasing a radiation source, the local radiation protection coordinator must always be notified.

 Checklists for new acquisitions may include:

• Who is the owner (in the case of joint procurement involving multiple units)? The owner shall ensure that sources subject to mandatory reporting under section 13 of the Radiation Protection Regulations are reported in the Norwegian radiation and nuclear safety authority’s electronic reporting system for radiation sources prior to acquisition.
• Who holds the primary responsibility for health, safety, and environment (HSE) during procurement or joint operations with other parties (e.g., SINTEF)? The involved units shall develop a coordination agreement
•  Who will perform maintenance and service?  Are there service agreements in place?
• Is special shielding required to protect adjacent rooms or neighboring operations?
• Use the procurement department’s checklist for major purchases. At the same time, assess whether there is a need to acquire safety equipment and necessary shielding equipment.
• Ensure that the radiation source is delivered with labeling in Norwegian as well
• Contact the building services if advice is needed regarding cleaning procedures, ventilation requirements, and more.
• Contact the Property management department if building-related technical modifications are required

Incidents and Accidents

Accidents involving radiation sources must be immediately reported to the line manager, the local radiation protection coordinator, and the central radiation protection coordinator. Incidents and accidents must be reported as deviations in accordance with the Guidelines for reporting and follow-up of HSE Deviations. See also NTNU’s emergency preparedness plan and radiation protection – emergency procedures for incidents and accidents.

The central radiation protection coordinator at the HSE Department shall assist with any required reporting of notifiable incidents to the Norwegian radiation and nuclear safety authority (DSA).

Annual Report

An annual report must be submitted to the HSE Section by February 1st each year. The HSE Section will distribute the reporting form by January 1st.

Definitions

The term radiation sources refers to the following sources as defined in the Radiation Protection Regulations:

• Radioactive sources
• Class 3b and 4 lasers
• UVC sources
• X-ray devices
• Accelerators
• Magnetic fields and other non-ionizing radiation sources that may exceed established exposure limits (as defined in the regulations).

Radiation: Ionizing and non-ionizing radiation.

Ionizing radiation: Radiation that has sufficient energy, in the form of particles or electromagnetic radiation, to remove an electron from the atom and/or molecule it hits, thereby creating an ion. This means radiation with a wavelength of 100 nm or shorter (energy above 12.6 eV).

Non-ionizing radiation: Electromagnetic radiation with energy that is not sufficient to ionize the atom and/or molecule it collides with. This means radiation with a wavelength longer than 100 nm (energy below 12.6 eV), as well as electric and magnetic fields.