Inspection report: ARPANSA Radiation Health Services (RHS), Yallambie VIC, (R24/04045)

Effective control

ARPANSA has a series of documents that outline how it maintains effective control over controlled apparatus and controlled material held under ARPANSA licences:

• RHS (S0002)
• Medical Radiation Services (MRS) (S0003), and
• prescribed radiation facilities operated by MRS (F0046).

The main overarching document, ARPANSA’s plans and arrangements, is the Radiation Safety Management Manual – version 4.1 (RSMM). The remaining sub-ordinate documents are referred to by links in the RSMM. There was no evidence that all of these subordinate documents had been reviewed in the last 3 years as is required for the overarching RSMM document and this can therefore be considered an AFI.

The RSMM prescribes ARPANSA’s approach to radiation safety including alignment with the WHS Policy, ARPANSA’s protective security policy and the requirements of the Act and Regulations. The RSMM outlines the procedures to be used by staff when carrying out radiation work and defines their roles and responsibilities for radiation safety. However, the RSMM contained several discrepancies such as:

• the inclusion of ‘and/or’,
• use of ‘should’ for mandatory requirements instead of ‘must’ (or ‘shall’),
• outdated terminology, e.g. ‘radiation workers’,
• inconsistent timeframes for documentation retention, etc. This is considered to be an AFI.

Accountabilities & Responsibilities

Section 4 of the RSMM describes the roles and responsibilities of a range of entities within ARPANSA broadly classified into two groups, those with radiation safety specific roles and those with specific radiation safety responsibilities. The table included in Section 4 provides more detailed information for each group including, but not limited to, the CEO, the Radiation Safety Committee (RSC) and workers.

It was noted that ARPANSA workers were obliged to meet a series of radiation safety objectives in this table although there did not seem to be any sanctions on a worker or group of workers should they not meet those obligations. This situation would require clarification in future revisions of the RSMM.

Management commitment

The RSMM outlines the licence holder’s commitment to radiation safety compliance, and compliance with the Act and Regulations. However, subsection 9.3 required the ARPANSA senior management team to perform a full review of all aspects of the RSMM at planned intervals. The subordinate ARPANSA-SOP- 0925 states that the management review meeting is conducted twice per year.

There was no evidence that such a meeting had taken place in recent years. This was identified as an AFI. The same AFI was also identified in the 2023 inspection of the MRS Branch (S0003) which uses the same RSMM and organisational Radiation Safety Officer (RSO).

Statutory & regulatory compliance

The licence holder’s quarterly reports have been submitted to ARPANSA Regulatory Services in a timely manner and contained relevant information on the licence holder’s compliance activities.

Safety management

Safety policy & objectives

Section 6 of the RSMM outlines the licence holder’s commitment to achieving radiation safety objectives

along with the commitment to upholding the principles of radiation protection and safety.

Subsections 6.1.3-6.1.7 of the RSMM contain more specific coverage of ionising radiation, non-ionising radiation, classification of exposure groups, limiting exposure and dose constraints and action levels. Section 6.1.7 does, however, contain the statement:

… an ARPANSA wide dose constraint for radiation workers [sic] has not been set.

as the RSMM indicates that routine work at ARPANSA is not expected to exceed the annual public dose limit of 1 mSv per year.

Not having a formal dose constraint is considered an AFI.

Monitoring & measurement

Section 7 of the RSMM outlines the requirements for periodic radiation monitoring of work areas. Records showed that area monitoring and surveys are performed as appropriate.

Radiation measuring instruments are calibrated in accordance with the requirements of AS/NZS 2243.4 with instrument calibration for all monitoring equipment managed by Radiation Health Services.

Training & education

Section 7 of the RSMM details the radiation safety induction and refresher training requirements. Training records were found to be up-to-date. However, subsection 7.3 of the RSMM itemises appropriate levels of knowledge of radiation safety controls for inductees, including personal protective equipment requirements and isolation procedures. Neither of these aspects were seen in the training documentation, thus representing an AFI.

Information provided during the inspection indicates that RHS personnel have received relevant radiation safety training.

Radiation protection

Radiation safety committee

The RSMM specifies that the RSC meet at least 4 times per year, chaired by the ARPANSA RSO and attended by the Deputy RSO, and Radiation Protection Advisers. An example of a quarterly RSC meeting agenda and minutes were viewed.

Planning & design of the workplace

The design of all workplaces observed during the inspection were considered to meet the requirements of the relevant Australian standard.

Local rules & procedures

The following observations were made during a walk-through inspection of RHS laboratories and storage rooms.

General

Some entries in the source inventory workbook were inconsistent with their actual location in the laboratories and another was entered as being at the incorrect street address for ARPANSA.

Room 327A (radioisotope laboratory (RIL))

The following AFIs were identified during the inspection of the RIL:

• AS/NZS 2243.4 requires that working procedures and contingency plans be displayed in laboratories using unsealed radioactive material. However, these were only available online. Although available under normal circumstances, access to these documents would be restricted in the event of computer failure. It is acknowledged that while paper documents have their drawbacks, such as lack of version control and potential for contamination, the advantages of immediate availability of such information outweighs the disadvantages.
• There were no formal personal contamination reporting requirements (clause 4.8.5(p) of AS/NZS2243.4) although such reporting could happen as part of general work health and safety incident reporting. No evidence of this was provided during the inspection.
• The vacuum cleaner in the entry area to the RIL was not fitted with high efficiency particulate air filtration (HEPA) as required in clause 4.8.5(q) of AS/NZS2243.4.

Room 137 (radiation store)

Access to the store was unable to be gained during the inspection although all external aspects of the store including limitation of access, labelling and external dose rates appeared to meet the requirements of Section 5 of AS/NZS 2243.4.

Room 345A (UV Calibration Laboratory)

The permit showing the names of those with approved access was not evident during the walkthrough although this was replaced before the inspectors’ departure.

Personal Radiation Monitoring Service (PRMS) office area

Strontium-90 calibration sources were stored in a locked safe in a low occupancy room adjacent to the PRMS office area. While inherently safe, it would be prudent to store such sources either with the other PRMS calibration sources or in the radiation store.

Personal protective equipment (PPE)

PPE was available in accordance with relevant Australian standards for each laboratory visited during the inspection.

Monitoring of individuals

The personal radiation dose monitoring and dose record keeping requirements for each monitored staff are specified in the RSMM and was managed in a satisfactory manner. The RSO has oversight over wearer dose reports and investigates abnormal doses if appropriate, and reports on dose records as required by the RSMM.

Radioactive Waste

Management of radioactive waste

The RSMM specifies storage requirements for radioactive sources. All storage areas inspected were found to be in accordance with relevant ARPANSA requirements and the storage requirements of AS/NZS 2243.4.

Section 8.5 of the RSMM referred to several regulatory bodies by different titles (e.g. relevant Authorities, local statutory authority, State Authorities, relevant Regulatory Authority) without defining who these authorities were. It was unclear if these regulatory authorities were one and the same or different. Such referencing could create confusion regarding who to consult when disposing of radioactive material and this would need to be reviewed for future versions of the RSMM.