RPPM 5.0 Possession and Use fo RAM

5.1 Possession and Use of Dispersible Radioactive Materials

5.1.1 Authorization, acquisition and control of radioactive materials

An authorization to acquire, store and use radioactive materials (RAM) may be obtained by permanent faculty and staff of the University though the submission of an Authorization application to the RSO for processing and review and approval by the Radiation Safety Committee (see RPPM Chapter 3 and B).

Approved and active Authorizations may acquire radioactive materials through purchase from commercial provider; through intra-University transfer from another AU; or by external transfer from a properly licensed and authorized provider (Federal contractor, licensed donor entity, licensed co-researcher, etc.) (see RPPM 3 and B).

All Authorized Users planning to receive an incoming transfer of radioactive materials should pre-notify the RSO to assure:
The Authorization is approved for the acquisition;
The RSO can pre-verify the licensing of the provider and shipper qualifications before the transfer is initiated;
All required transport, shipping, receipt and on-campus transfers and deliveries are properly documented, coordinated and completed in an efficient and compliant manner.

No transfer or receipt of RAM is to occur directly to an AU or University facility. Deliveries on the Pullman campus must be received through:
Central Receiving;
The RSO;
An RSO pre-approved direct delivery protocol (i.e. – radiopharmacy courier direct delivery).

All receipt of RAM is immediately entered into the RSO RAM inventory tracking system to maintain a record of the material from the receipt through to the disposal or transfer of the material out of the University inventory.

When RAM is held in inventory under an Authorization, it must be held in a secure, restricted access facility that is an approved use area for the Authorization. RAM stocks and stored wastes must be secured so that they are accessible only to radiation workers listed on the Authorization (see RPPM 10. A).

Federal and State “cradle to grave” tracking requirements require that there be no co-mingling of RAM stock inventories or RAM wastes that are held under different Authorizations.
Authorizations that share a facility must each have:
A separate, secure storage location, accessible only to the workers listed on the Authorization;
Separate and fully labelled radioactive waste holding containers.
Proper adherence to RSO RAM transfer pre-approval protocols allows the University to maintain appropriate records to maintain compliance requirements.

5.1.2 Facilities appropriate for the use of dispersible forms of RAM

An Authorized User must perform their work with radiation in a facility suitable for the proposed use and associated safety risks. Prior to approving an Authorization application, the RSO and RSC evaluate all listed facilities and radiation use areas for suitability based on the following criteria:
Each proposed use area and its associated safety equipment (i.e. – fume hoods);
The radiation protection equipment that will be made available before initiating the proposed radiation use;
The risk of a contaminating event associated with the proposed project;
The AU’s, sponsoring department’s and University’s ability to quickly and effectively control the consequences of a contaminating event.

Most laboratories at the University meet the basic requirements for use of tracer

levels of dispersible forms of radionuclides and meet the following requirements:

Any area where hazardous materials are used must have adequate ventilation. Room air must circulate from clean areas toward the more hazardous use area(s) and then exhaust directly to an appropriately placed outside vent (no recirculation of exhaust air);
Hazardous materials use areas must:

Be uncrowded with suitable traffic-flow patterns;

Be suitable for implementation of access restrictions and appropriate level of security;

Have at least one direct access, lockable side-room where radioactive wastes can be stored;

Have smooth, contiguous, non-absorbent surfaces that are easily cleanable on walls, floors and work surfaces;
Have a properly installed and working chemical fume hood with flow rates of at least 80-120 cu. ft/min when the sash in the normal working position;
Have an adequate number and placement of sinks and safety eyewash stations and showers.

5.1.3 Safety and compliance protocols for use of dispersible forms of RAM

Radiation safety begins and ends with the Authorized User and their radiation workers. Regulations, policies and standard protocols are only effective if workers understand that regulations, policies and protocols are in place for a very good reason…. The worker’s safety !

Safety is maintained by proper training of workers and adherence to the concept of ALARA.
Prior to being approved as a radiation worker and prior to any handling or using any source of radiation, a worker must complete the basic radiation safety training modules that are applicable to the planned use of radiation (rso.wsu.edu/training/training.html);
The Authorized User and/or their laboratory supervisor must provide workers with:
Specific hazardous awareness training for all hazardous materials present in their restricted area to anyone allowed un-supervised access to a restricted facility;
Documented function and task specific training appropriate to the sources of radiation and work they will be performing (i.e. – if a radiation worker will be handling a dispersible form of RAM, they must know the safety hazards of the radionuclide(s) and be able to properly perform and document a contamination survey);
Spill and emergency response training (i.e. – Each Authorization is to have a written protocol that workers are familiar with covering the steps a worker is to follow if there is a personal injury or spill of material in the lab; or a fire in the building).
The RSO will audit Authorizations radiation active use areas (see RPPM 3 and B) to assure that:
Radiation worker knowledge and skills are appropriate to the radiation uses and responsibilities they are performing;
Training and spill and emergency response documents are available to workers.

The WA DOH provides minimum safety and use guidelines for small laboratory licensees that use dispersible forms of RAM.
Copies of the WA DOH guidance documents are provided in B.
WA DOH inspects University radiation use areas (labs) on a routine basis. It is appropriate that all University workers who handle dispersible forms of RAM know and adhere to the recommendations made in these WA DOH guidance documents.

Authorized Users and radiation workers must assist in the maintenance of compliance to the ALARA principle by:
The use of proper of shielding, dosimetry and contamination control techniques whenever handling or using a dispersible form of radioactive material;
Taking proper precautions to assure their safety and the safety of their work area through :
Awareness of potential radiation hazards, exposure levels and safety controls in their work areas;
Awareness of operating and emergency procedures;
Awareness and intervention when practices that do not follow the ALARA philosophy;
Reporting incidents and any unsafe working condition to their supervisors and, if
appropriate, to the RSO;
Wearing personnel dosimetry and ensuring its return to the RSO in a timely manner and at the proper exchange frequency.
Adhering to the ALARA principles when working with dispersible forms of RAM, controlling the risks of RAM being inhaled, ingested or absorbed by direct contact by:
Not bringing food, drink or cosmetic products (i.e. – lip gloss) into a RAM lab;
Performing frequent swipe surveys and lab area monitoring of work areas, hoods, sinks, refrigerators, phones and computer keyboards, etc.
Prevention of contamination through the use of absorbent paper, spill trays, properly labeled waste containers, etc.;
Use of equipment capable of detecting contamination as it occurs (survey meter);
Prompt and complete decontamination when contamination is identified;
Use fume hoods whenever handling materials which could become airborne (e.g., vapors, dust, aerosols, etc.);
Use of appropriate personal protective equipment (PPE) such as disposable gloves, safety glasses, lab coats, etc.

Radiation workers have the right to ask the RSO (wsu.edu) or the WA DOH Office of Radiation Protection to conduct an inspection if the worker is concerned that their work area has a radiation safety problem related to the use or storage of sources of radiation.

5.1.4 Safety and compliance protocols for disposal of radioactive wastes

Radioactive waste minimization and management plan
Waste management must rank high on the priority list of all radiation workers.
The Authorization needs a radioactive waste management plan, prepared by the AU and lab supervisor that all workers know and adhere to for every task, every day.
The waste minimization plan must be considered as a research protocol is developed and as the Authorization application is being prepared. The following questions must be considered:
Are there suitable alternatives to using radionuclides for the research project ?
How much radioactive material inventory will be needed and how can an adequate inventory of radionuclide(s) be maintained without ordering and storing more radioactive material than is needed ?
Is there an alternative method(s) of radioactive waste disposal that does not require the collection, packaging and shipment to a commercial radioactive waste disposal site (i.e. – recycling; transfer to another AU who can use it; return to the manufacturer; decay-in-storage; etc.)?
If the generation of mixed waste (RAM+ regulated chemical) cannot be avoided, can the waste be modified within the research area to eliminate one of the hazard classes, thereby converting it to a single hazard waste (i.e. – decay-in-storage) ?

Training and Personal Protective Equipment for Radiation Workers handling radioactive wastes
Radiation Workers must be current on their required basic radiation safety training and annual refresher training;
Radiation Workers assigned duties involving radioactive waste management must receive training from the AU, or their designee, specific to the specific hazards present in the waste; waste minimization and segregation requirements; surveying, packaging, labeling and recordkeeping requirements; and preparation and scheduling for transfer of waste containers to the RSO for further processing and disposal;
The use of proper PPE is required for all individuals handling radioactive waste (i.e. – lab coats; shoes or boots; dosimetry; eye protection; gloves);
If requested by an AU, or if needed based on an RSO assessment of function specific technical knowledge and performance by radiation workers, the RSO will provide in-lab training in RAM waste management practices.

General Guidance for Management of RAM Waste in Labs
- Most radioactive wastes generated in labs and other approved facilities must be segregated in the lab when the waste is being generated. All radioactive wastes are to be segregated properly and placed into an appropriately labeled, standardized waste container(s);
RAM waste storage locations should be:
A posted, restricted access area away from the general work area;
Lockable and accessible only to workers listed on the Authorization that created the waste;
Surveyed monthly with the surveys properly documented and available for inspection.
- Waste containers must be properly shielded to assure the exposure level near the container is ALARA (i.e. – < 2 mrem/hr);
- If a waste container or the adjacent area (floor) are found to be contaminated (> 2x background), it must be decontaminated, re-surveyed and documented to be free of contamination;
- When a waste container is “full” or needs to be taken out of an active use area it may be:
Transferred to the RSO waste management program for storage or processing through to its final disposal (see RPPM 3 and 10B and 10E).
Placed into storage at the AU’s facility as a “decay-in-storage” (DIS) waste container if it meets the following requirements:
It contains only radionuclides with half-lives of < 90 days;
It is properly packaged, sealed and labeled and in RSO-approved, standardized radioactive waste container;
It can be stored in a properly posted, restricted access storage location for the duration of the required decay period;
It can be surveyed by a trained radiation worker at the end of the calculated decay period (10 half-lives), using an appropriate radiation protection survey meter, to verify that the waste container has reached a releasable radiation hazard level;
The DIS process (pre-approved by the RSO) can be properly documented with records of the container contents, the release survey results, and the final disposition of the waste (i.e. – container released to a landfill waste stream with all container radiation labels obliterated).
The RSO will audit and monitor all active radiation use and storage areas to assure that radioactive waste is:
Not being created unnecessarily;
Stored in a clean, secure area that is routinely surveyed;
Being managed within acceptable guidelines.

Laboratory Release of Aqueous Liquid RAM Waste to the Sanitary Sewer
Drain disposal of significant amounts of radioactive material by a RAM user or laboratory group is prohibited.
A laboratory on the Pullman campus may request approval for the disposal of a limited amount of aqueous-based liquid, non-alpha radioactive waste of low concentration via the sanitary sewer.
The Authorized User should contact the RSO waste management program coordinator (radsafe@wsu.edu) to request and establish an RSO pre-approved protocol for the release of RAM to the sanitary sewer via a pre-designated and posted sink or drain.
Any Authorization approved for a sanitary sewer discharge protocol must record and report their drain discharges to the RSO waste program coordinator on an on-going and routine basis (see RPPM10E).

Authorization Release of Radioactive Materials to the Air
Some Authorized Users may be pre-approved by the RSO for specific and limited release of a radioactive gas (radioactive waste) that is generated due to a research process. Such a release must be through a properly operating fume hood or other approved device.
The Authorized User must submit a Summary of Radionuclide Disposals to the Air to the RSO on a monthly basis estimating the quantity of the specifically-approved radionuclide(s) released (see RPPM 10 E, RSO Forms);
The RSO waste management coordinator will enter the information into the waste and inventory databases and record total discharges/month to assure RAEL compliance is maintained.

5.1.5 Transfer of RAM Stock Inventory to another Authorized User or Licensed Recipient

Upon the termination of a research project or an Authorization, it may be appropriate to transfer useable radioactive stock materials or sealed sources to another similar Authorized research project that is already approved for possession and willing to accept the donation.
An AU, or their laboratory supervisor, should consult with the RSO waste program coordinator prior to designating unused, good quality RAM stocks or sealed sources as radioactive waste;
The following alternatives may be available for the management of unneeded or recyclable radioactive materials:
Donation to an alternate AU within the University;
Transfer to an appropriately licensed individual or entity outside of the University (i.e., licensed specifically for the radionuclide, form, and use per an appropriate NRC or Agreement State license).

[NOTE: The RSO must verify that the recipient is properly authorized to receive the material using one of the methods described in 10 CFR 30.41 prior to transferring radioactive material. Any shipment or transport must be compliant with DOT regulations]

5.2 Possession and Use of Sealed Sources

5.2.1 Authorization, acquisition and control of sealed sources

Definition and Designation as a sealed source of radioactive material
The requirements for designation of a source of ionizing radiation as a sealed source is described in RPPM 3.4.5 and is based on the definition used in WAC 246-220-010 and 246-247-030(24) .
“Sealed source” means any radioactive material that is encased in a capsule designed to prevent leakage or the escape of the radioactive material.
For Authorization administration purposes, the final designation of whether a material is characterized, inventoried, tracked, handled and controlled as a sealed source under the University Broadscope license is made by the URSO, following any needed clarification from the WA DOH Office of Radiation Protection.

Policies regarding the acquisition, possession, security and disposal of sealed sources can be found in SPPM Chapter 9.

The RSO support program and services for the inventory and management of sealed sources are described in RPPM 3.4.5.

An RSC-approved Authorization is required for the possession and use of a sealed source(s) or equipment containing a sealed source unless an exemption is granted due to a very minor quantity of possession (i.e. – small calibration sources or physics teaching sets).
An Authorization may be approved to hold in inventory both dispersible and sealed source forms or just sealed sources of radioactive material.
A sealed source that is a component of an instrument or is within a manufacturer-installed component in an instrument.
Must be listed in inventory and tracked until it is disposed of or transferred out of the University’s RAM inventory;
The RSO must perform documented leak tests on the instrument component containing the sealed source on an every 6 month basis.
Although some instruments may be manufactured or distributed as “generally-licensed” (i.e. – may be sold to the general public), as soon as any RAM is held in inventory under a broadscope license, it must be tracked in inventory through to its proper disposal or transfer off the license;
The RSO should be notified of:
Any planned acquisitions of sealed sources or equipment containing a sealed source, even generally-licensed items;
All sealed sources in the possession of a staff member, department or Authorized User or any sealed source discovered at a University facility which had not previously been tracked by the RSO (i.e. – “orphan source” with no declared owner);
Any planned disposal of generally-licensed devices that contain radioactive materials.

Each Authorized User must have a standard protocol for managing the sources under their inventory:
All sealed sources should be maintained within secure storage cabinets, safes, or at a lockable designated location within the laboratory. Each storage location should have an inventory of the sources stored at that location;
A suitable labeled and shielded storage container should be used for each source or calibration or teaching set of sources;
When not in active use, a sealed source is to be secured in the locked location that is accessible only to workers listed on the Authorization.
A use log is to be used to record when a source has been removed from its storage location for use. The Log is to contain the following information:
The specific source identification information;
The radiation worker taking responsibility for possession, control and proper handling of the source while it is out of its secure storage location. This individual must be listed on the Authorization and must have documented training for the requirements of source use.
The planned use description and use location;
The estimated time of return (date/time);
The return date when the source is placed back into storage.
At physical inventory of the sources in inventory must be completed and documented at a minimum of monthly (weekly checks will assure better security). A chronological record (log) should be maintained that shows the date and personnel performing of inventory checks, and that all sources were in inventory and were undamaged.
The RSO and public safety must be notified immediately if a source of ionizing radiation is found to be missing so that an immediate investigation and, if needed, a hazard alert can be issued.

5.2.2 Safety and compliance protocols for the use of sealed sources

Radiation worker safety is maintained by proper training, adherence to the concept of ALARA and having in place the proper protocols for all use of sources of radiation. There is no real elimination of risk because a sealed source is being used. Sealed sources can be both:
An external exposure risk to workers and the general public;
A contamination hazard when the assumption is made that there is no contamination risk.

Radiation workers who work under an Authorization that uses sealed sources complete the basic radiation safety training modules appropriate for sealed source users (RSO training).

The Authorized User, and/or a qualified laboratory supervisor, must provide:
Specific and documented hazardous awareness training for all workers and visitors allowed un-escorted access to the radiation use or storage area (RPPM 10A);
Radiation worker function and task specific training appropriate to:
The radionuclide(s) held in a sealed source form and risks associated with it;
The duties and responsibilities assigned to the worker.
Emergency response training (i.e. – protocol to be followed in the event of a personal exposure or injury; breach of a sealed source; or a fire in the building).

General Radiation Safety considerations for sealed sources of radiation
Sealed sources emit radiation and their use is associated with a potential for external radiation exposure;
Although a sealed source is manufactured to be “sealed”, sealed sources can be damaged and can release material, resulting in unexpected contamination.
There is only one way to assure control the potential for contamination when using a sealed source, and that is by always handling a sealed source with the understanding that is may be breached unexpectedly. Alway workers are to wear proper PPE when handling a sealed source

ALARA principles must be followed when working with sealed sources, including:
The use of sealed sources that produce an adequate, but not excessive, radiation field for the task required;
The handling devices not less than 15 cms long to maintain distance from the user’s hands:

No radioactive substance in the form of a sealed source should be held in an ungloved hand or manipulated directly by hand if the instantaneous dose rate to the hand exceeds 75µSv/hr (7.5 mrem/hr). NOTE: Even small gamma reference sources can have surface dose-rates as high as 13.5mSv/hr (1.35 mrem/hr) for a 0.5MBq source.
If a ring dosimeter has been provided to the worker it must be worn under the glove when handling a sealed source. The ring dosimeter label must be faced toward the sealed source surface for it to correctly record the exposure;
Any handling of the source (i.e. – installing in equipment) should be performed by a trained and experienced radiation worker who is familiar with:
The particular source, radionuclide and its properties and inherent hazards;
The proper protocol for use and the precautions to be taken when handling the source.

Laboratory storage and control of sealed sources
A radiation worker should be in charge of the sealed source storage location; the inventory of all sealed sources; the use log; and assuring the timely return of sources to their storage location.
At a minimum, the sealed source inventory should be verified at least once a month and the locations of all sealed sources checked-out for use must be verified.

5.2.3 Sealed Source Inventory Tracking

The RSO maintains a tracking database of all sealed sources held in inventory to comply with reporting directives and requirements of licensing and governmental oversight entities;
- The information tracked by the RSO for compliant records management includes the :
Radionuclide(s) within a sealed source;
Source manufacture date, model number, activity, serial number;
Any assigned uniqueIdentifier;
Current activity of the source, with a running accounting for decay;
Authorized User or entity in possession and control of the source;
Secure storage location of the source.

The RSO also maintains operational data that is required by regulation:

Activity of the source at time of receipt and current activity (decay corrected);
Physical inventory dates;
Wipe test dates and results;
Disposal record, whether the removal from inventory is through decay to a releasable level; transfer to an alternate licensed entity; or disposal as radioactive waste.

5.2.4 Sealed Source Leak Test Performance and Records Management

To maintain compliance to the regulatory requirements the RSO performs a physical inventory and appropriate leak test on all sealed sources multiple times per year.

When a sealed source is not in use (i.e. – long term storage within shielded containment), the properly labeled and sealed storage container will be inventoried and the leak test will be delayed until immediately prior to the next use or transfer of the source.

The RSO performs leak tests on all sealed source containing more than 100 μCi of beta and/or gamma emitters and greater than 10 μCi of alpha emitters at least every six months or after any after any damage is discovered to a source and will:

o Take the wipe sample from the surface of the source or at the nearest accessible point to the sealed source where contamination might accumulate;

o Analyze the wipe sample for the presence of contamination by a procedure capable of detecting the presence of 85 Bq (0.005 microcurie) of radioactive material on the test sample.

The detection and confirmation of a leaking sealed source will require immediate RSO confiscation of the source to assure:
Proper control and containment of any further spread of contamination;

o Decontamination, repair, or proper disposal of the source.

· The RSO will assist the Authorization’s radiation workers in:

The performance of needed surveys: personnel and facility decontamination(s) or disposal, as appropriate, of all equipment associated with the leaking source;

Preparing required records documenting the discovery and resolution of contamination.

5.2.5 Possession and Storage of Equipment Containing a Sealed Source

Laboratory equipment such as gas chromatographs, liquid scintillation counters, analytical balances and static eliminators may contain sealed sources of ionizing radiation and are subject to the same policies and use protocols as are all other sealed sources.
The physical location of the equipment must be posted and security maintained to assure the device is secure.
Dismantling these devices for cleaning could result in the release of the radioactive material, therefore precautions should be taken to prevent exposure (i.e. – the worker must use appropriate PPE).
Do not relocate equipment that contains a sealed source on a campus or between campuses without RSO pre-approval of the method of transport or the new location.
Do not dispose or transfer the equipment to any other user or to surplus services without pre-notification and pre-approval of the RSO.

Some types of gas chromatography equipment contain small radioactive sources.
The sources are usually³H or ⁶³Ni electroplated onto metal inside an electron capture device.
Gas chromatography equipment containing³H releases a small amount of ³H during normal use.
Operating at an excessive temperature may cause large releases from both³H and ⁶³Ni devices.
All gas chromatography equipment containing radioactive material must be exhausted through tubing either into a chemical fume hood, out a window, or through a manufacturer’s approved trap.

5.2.6 Possession and Management of Am-241/Be Moisture/Density Gauges

All radiation workers handling these devices must complete manufacturer-provided training and must complete and document RSO-provided on-line training for users of moisture and density gauges.

The RSO will provide all regulatory-required training related to the security and transport of these devices and will provide appropriate shipping papers that must be in the vehicle when these devices are taken on public highways.

The AU is required to list all users on their Authorization and to provide function-specific hands-on operational training to any radiation worker authorized to use a moisture gauge.

A training log is to be maintained listing:

The radiation workers completing the training and the date;
The training instructor;
The topics covered.

Transport papers will be prepared by a qualified RSO shipping coordinator for each gauge that will be transported on public highways. Transport papers must be in the transport vehicle with an authorized user during any transport of a gauge device that contains a sealed source of radiation.

5.2.7 Disposal of sealed sources

All sealed sources must be controlled and documented through to their proper disposal or transfer to a licensed entity (i.e. – return to the manufacturer).

Contact either the RSO Sealed Source or Waste Management Program coordinator (wsu.edu) to discuss transfer or disposal options for sealed sources or equipment that contain a sealed source.

Transfer of a Sealed Source as a Means of Disposal
A useable sealed source may be transferred to an alternate Authorization that has a use for the source, is willing to accept the source, and is already approved for possession of the radionuclide;
Sealed sources and equipment-installed components containing sealed sources may be transferred to an alternate, properly licensed recipient or may be returned to the manufacturer for re-use or disposal.

[NOTE: The RSO must verify and document that the recipient is properly authorized to receive the material using one of the methods described in 10 CFR 30.41 prior to transferring radioactive material. Any shipment or transport must be compliant with DOT regulations]

All sources that are depleted below a useful activity or that are no longer needed by an Authorization should be transferred to the RSO waste disposal program.
No sealed source is to be discarded into the normal waste stream or transferred to a non-licensed individual or entity, even sealed sources that were obtained originally as generally-licensed items.
The University is not approved to distribute generally-licensed sources of radiation;
Disposal of depleted sealed sources as normal waste and into a landfill is not “proper disposal” under a Broadscope license.