II. Responsibilities and Lines of Authority
ultimate responsibility for all activities at
II.A. Administrative Structure
Vice Provost for Research governs the use and control of nuclear radiations,
radioactive materials, and radiation machines through a dual, parallel
structure. All such activities
pertaining directly and solely to the nuclear reactor, as permitted by the Nuclear
Regulatory Commission license issued to WSU, are supervised by the Director,
Nuclear Radiation Center and an oversight committee called the Reactor
Safeguards Committee. (This committee is
a Presidential Committee whose members are appointed upon recommendation of the
Vice Provost for Research. The Director,
Radiation Safety Office is an ex officio member of this committee.) All matters of radiation safety in the
The Radiation Safety Committee has purview over all aspects of control of radiation not directly and solely related to the nuclear reactor. The charter of this organization follows.
II.B.1. RADIATION SAFETY COMMITTEE CHARTER
a. Function and Jurisdiction
Radiation Safety Committee (hereafter referred to as "the RSC") shall
review, evaluate and approve: safety
standards, facility standards, training requirements, and license requirements
associated with the use and disposition of radioactive materials and radiation
machines, in accordance with the requirements of WAC 246-235-090
(2)(c), except for facilities and activities governed by Federal
License. The Committee shall retain right
of review and approval of all radioisotope procurement and utilization at
WSU. Its jurisdiction shall include all
operations coming under the jurisdiction of the State of
(1) Safety Review
The safety review responsibility of the RSC or designated subcommittee thereof shall include, but is not limited to, the following:
(a) Review and approval of all proposed uses of radioisotopes and radiation machines,
(b) Review and approval of all radiation machines and those facilities associated with the use, storage, and disposal of radioactive materials as to adequacy for such use,
(c) Review and approval of all prospective radioisotope users as to the adequacy of their training and experience to engage in research utilizing radioactive materials,
(d) The RSC may delegate any of the above responsibilities by administrative procedure to the Radiation Safety Office,
(e) Review and approval of all proposed
changes to the State of
(f) Review of the operation and operational records of the Radiation Safety Office, and
(g) Review of unusual or abnormal occurrences
encountered by the Radiation Safety Office and/or radioisotope users, and
review of incidents which are reportable under the State of
The audit responsibility of the RSC or designated subcommittee thereof shall be to audit all operations under the jurisdiction of the Radiation Safety Office annually with an interval not to exceed 16 months.
c. Composition, Tenure, Selection and Officers
(1) Composition and Tenure
The RSC shall be composed of at least eight (8) University faculty or staff knowledgeable in fields which relate to radiation safety, plus the Assistant Director, Radiation Safety Office.
The Vice Provost for Research or designee and the Director, Radiation Safety Office shall be a permanent member of the Committee. Each of the six other voting members of the Committee shall serve for a term of three years. The Assistant Director, Radiation Safety Office shall serve as an ex-officio, non-voting member of the Committee.
Faculty and staff members shall be appointed by the President of the University upon recommendation of the Vice Provost for Research.
Committee Officers shall consist of the Chairman and the Secretary. The Chairman of the Committee shall be a regular voting Committee member, shall hold a full-time permanent faculty or a staff appointment, and shall be appointed Chairman by the President of the University. The Secretary of the Committee shall be the Director, Radiation Safety Office.
d. Quorum, Voting Rules and Meeting Frequency
The participation of the Vice Provost for Research or designee and Director, Radiation Safety Office and at least three other voting members shall be required for Committee action.
(2) Voting Rules
Committee action shall be decided by majority voice vote of a Committee quorum. Each Committee member shall have one vote per motion.
(3) Meeting Frequency
The RSC shall meet at least quarterly, with intervals not to exceed four months. Additional meetings shall be conducted at such times as Committee review responsibility dictates. Meetings shall be called by the Chairman who shall contact individual members.
Subcommittees of at least three regular voting members may be designated by the Committee Chairman to perform review or audit functions as may be required.
f. Presentation to the Committee for Review
Submission of documents for review by the Committee shall be transmitted to the Chairman and Committee members by the Director, Radiation Safety Office. A written statement indicating the need and/or requirement for review shall accompany the document. The Committee may also request the submission of additional materials required in the performance of RSC functions.
The content of a document submitted for review by the RSC shall be determined by the nature of the item under consideration. Items of definition or clarification may be presented orally or in written form.
Prior to each meeting of the RSC, the Committee Secretary shall mail each member an agenda for the meeting along with copies of other documentation that will be submitted to the Committee for review during the meeting.
g. Records of Review
(1) Record of Review
The RSC shall maintain written records of its activities in the conduct of the review responsibility. The form of the records shall be meeting minutes compiled by the Committee Secretary. The Secretary shall distribute the minutes to all Committee members. The minutes shall include copies of the documents submitted to the RSC for review. The Secretary shall maintain a complete file of Committee minutes.
(2) Records of Audit
The RSC shall submit to the Vice Provost for Research a written report on audit activities performed, including results of audits and unusual or abnormal findings. The Secretary shall maintain a complete file of audit reports.
II.B.2. RELATED WSU STANDING COMMITTEES
Other University standing committees have purview over safety in a more general sense. Hence the Director, Radiation Safety Office serves on each of the following committees:
a. Health and Safety Committee
b. Safety, Sanitation, Biohazards, Radiation Committee
II.C. Radiation Safety Office
Radiation Safety Office functions as the control agency at
The mission of the Radiation Safety Office is to administer a program ensuring the safe use of radioactive materials and radiation machines in research, instruction, and service on the main campus, the outlying campuses, and the research extension centers.
The major objectives of the overall program are to minimize radiation exposure for personnel, both at WSU and in the larger
environment, and to furnish necessary services to users of radioactive materials and radiation machines.
Salient goals for the radiation safety program are
a. To improve radiation safety practices;
b. To develop in the health physics program the capability to evaluate with a predictive capacity any radiation-related health problems; and
c. To maintain a creditable level of protection while reducing overall associated costs inasmuch as feasible.
The general functions are tailored to the requirements for the program as specified in Title 246, Chapters 220-254 of the Washington Administrative Code and the conditions enumerated in Radioactive Materials License WN-C003-1 issued by the State of Washington Department of Health. These functions comprise:
a. Inventory control for radioactive materials;
b. Administration of an analytical x-ray equipment program;
c. Monitoring of personnel exposure to radiation;
d. Delivery of radionuclides to authorized users;
e. Collection, processing, and disposition of radioactive wastes;
f. Administration of a laboratory survey program;
g. Provision of courses in radiation safety to various categories of
h. Conducting leak tests for sealed sources; and
i. Calibration of portable survey instruments.
The organization of the Radiation Safety Office is displayed in the following block diagram.
The Radiation Safety Office must be staffed with sufficient qualified personnel to carry out the tasks required by state regulations and the WSU radiation protection program. The staff consists of at least:
a. the Director (Certified Health Physicist),
b. the Assistant Director ,
c. the Secretary Senior,
d. two Health Physicist,
e. three full-time radiation safety technicians, and
f. two temporary part-time student assistants during fall and spring semesters.
II.D. Director, Radiation Safety Office
The Director, Radiation Safety Office (DRSO), a faculty member of the university, has the following responsibilities:
a. The DRSO manages the university radiation safety program.
b. The DRSO advises the Chairman of the Radiation Safety Committee as to the status of the radiation protection program and recommends actions necessary to maintain the program in full compliance with federal and state requirements.
c. The DRSO serves as the Secretary of the Radiation Safety Committee.
d. The DRSO prepares an annual report of the radiation safety program that summarizes the past year's activities, discusses the status of the radiation protection program, and recommends any actions necessary to maintain the program in full compliance with appropriate regulations.
e. The DRSO ensures that all records required by applicable regulations are properly maintained and retained.
f. The DRSO supervises all routine and special radiation monitoring surveys including environmental monitoring as required by regulations, license conditions, or Radiation Safety Committee policy. The jurisdiction includes all university-owned or leased properties that may be affected by the use of radioactive materials and radiation machines.
g. The DRSO maintains close and continuous surveillance over all university uses of radioactive materials, except reactor special nuclear materials, so as to assure compliance with applicable state and federal regulations and license conditions.
h. The DRSO reviews each application for authorization to use radioactive materials and makes recommendations to the Radiation Safety Committee regarding each application.
i. The DRSO advises and assists prospective radioactive material users in the preparation of a program to use radioactive materials.
j. The DRSO proposes radiation safety policies for consideration and approval by the Radiation Safety Committee.
k. The DRSO establishes practices and procedures for the administration of the university's radiation protection program.
l. The DRSO conducts periodic training and information sessions for individuals exposed to ionizing radiation. The training must include appropriate information on the safe and proper handling of radiation sources and on the biological effects of radiation.
m. The DRSO assures that a copy of this manual is provided to each authorized user.
n. The DRSO prepares amendments to, and renewals, of, the Washington State Radioactive Materials License for review by the Radiation Safety Committee.
o. The DRSO establishes emergency procedures and supervises the handling of incidents involving radioactive materials held under the Washington State Radioactive Materials License.
p. The DRSO has the authority to terminate any work using radioactive materials held under the Washington State Radioactive Materials License which is conducted without proper authorization or which in his judgment is being carried out in an unsafe manner.
In many circumstances the Director, Radiation Safety Office is authorized to act without prior consultation of the Radiation Safety Committee.
a. Temporary Suspension of Authorization
The Director, Radiation Safety Office is granted the authority to rescind temporarily any authorization to use radioactive materials or radiation machines if in his judgment the continuation of that authorization
(1) presents an imminent risk to individuals or property,
(2) will very likely result in radiation overexposure,
(3) will very likely result in the violation of regulations, license conditions, or provisions of the initial authorization, and/or
(4) will result in serious adverse public reaction.
The Director, Radiation Safety Office should approach such action diplomatically by first discussing the matter with the Authorized User and then with that person's superiors, if necessary. When conditions dictate that the authority granted herein must be used, the Authorized User and his or her superiors will be informed in writing of the action and of the circumstances that justify the action. A copy of this statement will be sent to the Chairman, Radiation Safety Committee and the appropriate Dean or Department Chairman. The action of the Director, Radiation Safety Office will be reviewed by the Radiation Safety Committee. The decision of the Director, Radiation Safety Office will take precedence pending Radiation Safety Committee review.
b. Approval of Radioactive Materials Use
The Radiation Safety Committee authorizes the Director, Radiation Safety Office to approve the use of small amounts of radioactive materials, on a temporary basis, by non-authorized users without formal application and Committee approval. The DRSO approval must be recorded in the Radiation Safety Office. Such approval will encompass small sealed sources used for instrument calibration, equipment check, or reference standards. In the case of sealed source use, no single source will have an activity greater than allowed by WAC 246-221-300, Schedule B, minimum quantities of radioactive material requiring labeling, and approvals in any other cases will be limited to activity levels of the same order of magnitude as these exempt quantities.
c. Approval of Amendments to Authorizations
The Radiation Safety Committee authorizes the Director, Radiation Safety Office to give temporary approval for amendments to current user authorizations.
d. Approval of Initial Orders of Radioactive Material
The Radiation Safety Committee authorizes the Director, Radiation Safety Office to approve an initial order of radioactive material providing an application for authorization is pending and providing there are no unusual safety considerations in the application. However, the radioactive materials will not be delivered to the prospective authorized user until his or her use application has been approved by the Committee. Application of this authority by the Director, Radiation Safety Office is subject to review by the Radiation Safety Committee and may be modified at its discretion.
e. Gas Chromatographic Electron Capture Sources
The Radiation Safety Committee authorizes the Director, Radiation Safety Office to approve the use of Gas Chromatographic Electron Capture Sources without prior Committee review.
II.E. Authorized Users
Each person who has been authorized to use radioactive materials or radiation machines is responsible to the administration of the university and to the Radiation Safety Committee for full compliance with all pertinent provisions of the radiation safety program as promulgated and enforced by the Radiation Safety Office. This responsibility encompasses the safe use of ionizing radiation by all personnel involved in research conducted under the authorized user's purview and all pertinent activities carried out in the spaces authorized for research by that user.