1.0 Reason for Procedures

To set out Procedures secondary to the Policy entitled "Radiation Safety", in connection with the Radiation Safety program for all radioactive material, radiation devices and X-ray equipment in all areas under the control of the University of Manitoba.

2.0 Procedures

2.1 Radiation Protection Committee

The Radiation Protection Committee is authorized to:

(a) advise on the safe use of radioactive materials, radiation devices and X-ray equipment;

(b) make recommendations on University Policies and Procedures;

(c) approve standard operating procedures and guidelines;

(d) issue Internal Permits to control the use of all licenced activities involving radioactive materials, radiation devices and research X-ray equipment;

(e) enforce the Radiation Safety Program and to supervise the external and internal dose monitoring and verification of compliance

(f) make determination regarding revoking permits from individuals who contravene these Procedures or the Policy on Radiation Safety.

2.1.1 Membership

(a) The number of appointed members of the Committee shall not be more than ten (10);

(b) at least one (1) member of the Committee shall be a nuclear medicine physician to fulfill the role of medical advisor;

(c) one (1) member of the Committee shall be a supervising dentist with the Faculty of Dentistry;

(d) one member of the Committee shall be nominated by the Director of the Manitoba Institute for Cell Biology;

(e) one member of the Committee shall be from the bargaining unit representing technical support staff;

(f) one (1) member of the Committee shall represent academic staff;

(g) alternates shall be appointed during an extended leave of a Committee member; and

(h) the Radiation Safety Coordinator and the Assistant Radiation Safety Coordinator shall be non-voting members and shall act as resources to the Committee.

2.1.2 Officers

a) Chair

(i) the Chair shall be appointed by the Executive Director of Human Resources in consultation with the Vice-President (Research), Vice-President (Academic) and the Vice-President (Administration).

(ii) the Chair may participate to an equal extent as any other member of the Committee in the discussions and decisions;

(iii) the Chair shall select one (1) member of the Committee to act on behalf of the Chair in the event of his/her absence; and

b) Secretariat

The Environmental Health and Safety Office shall provide secretarial support to the Committee; maintain a file of all correspondence to and from the Committee, a record minutes of meetings and shall issue notices of meetings after consultation with the Chair.

2.2 Radiation Safety Officer

The Environmental Health and Safety Office is responsible for the provision of the function of the Radiation Safety Officer. The Radiation Safety Officer administers the Radiation Safety Program, acting in consultation with the Radiation Protection Committee. There shall be at least one individual at all times to fulfill the duties of the Radiation Safety Officer.

2.3 Internal Permit Holder

The Internal Permit Holder is responsible to:

(a) ensure that all Designated Workers as listed on their Permit are aware of all radiation safety procedures;

(b) ensure that all Designated Workers are trained to work safely with radiation and to provide site-specific training in the safe use of radioactive materials, radiation devices and X-ray equipment listed on the permit;

(c) regularly assess and inspect their areas for compliance with radiation safety procedures;

(d) ensure that any incidents that occur in their area are promptly reported to the Environmental Health and Safety Office; and

(e) adhere to all responsibilities as listed on the Internal Permit.

2.4 Designated Workers

Persons listed on an Internal Permit shall adhere to all responsibilities as listed in the Radiation Safety Manual and follow all relevant University Governing Documents.

2.5 Standard Operating Protocols

The Environmental Health and Safety Office shall develop and maintain the Radiation Safety Manual containing the Radiation Standard Operating Protocols related to this Procedure. The Radiation Protection Committee shall approve and enforce the Radiation Standard Operating Protocols.

2.6 Internal Permit

2.6.1 The Radiation Protection Committee issues an Internal Permit to control all procurement, use, storage, transfer and disposal of all radioactive materials radiation devices and X-ray equipment in all areas under the control of the University. The Internal Permit will specify:

(a) the Permit Holder;

(b) Designated Workers;

(c) Laboratory Radiation Supervisor (if one has been identified);

(d) permitted radioactive material and possession limits or radiation devices or X-ray equipment;

(e) approved locations;

(f) approved usage; and

(g) an approved disposal procedure, and other conditions of use.

2.6.2 The Internal Permit is conditional on the strict adherence to all conditions and parameters listed on the Internal Permit. The person whom the Internal Permit is assigned to is the Responsible User/Permit Holder.

2.6.3 The Internal Permit Holder shall ensure that there is full compliance with all the conditions specified on the Internal Permit.

2.6.4 Application for Internal Permit

A Principal Investigator shall complete an Application for an Internal Permit and submit it to the Environmental Health and Safety Office. The Radiation Safety Officer shall assess the application, and forward it to the Chair of the Radiation Safety Committee for approval.

2.6.5 Eligibility

(a) The Permit Holder is a Principle Investigator who is a Dean, Director or Department Head, or who is supervised by a Dean, Director; or Department Head.

(b) In order to use radioactive materials, radiation devices or X-ray equipment one must be:

(i) a Designated Worker (a person working under the authority of the Principal Investigator), or

(ii) In the case of X-ray equipment that is enclosed and interlocked by the manufacturer and has passed an X-ray leakage test, a person acting under the supervision of a designated worker on the related Internal X-ray Permit

2.7 Training

All Permit Holders and Designated Workers shall be trained in accordance with the Radiation Standard Operating Protocols as outlined in the Radiation Safety Manual. The Environmental Health and Safety Office shall keep copies of training documents.

2.8 Reports and Assessments

2.8.1 The Environmental Health and Safety Office shall make periodic assessments of all permitted activities. Inspections may be announced or unannounced. All users are required to cooperate with the inspection.

2.8.2 The Environmental Health and Safety Office may require periodic written reports from the Permit Holder.

2.9 Enforcement

2.9.1 On the first occurrence of an offence, the Permit Holder will be notified verbally by the Radiation Safety Coordinator or the Assistant Radiation Safety Coordinator of the offence with reference to the Radiation Safety Procedures.

2.9.2 On the second occurrence within a year of an offence, the Radiation Safety Officer will send a letter to the Permit Holder, as a "Notice of Non-Compliance" to the Permit Holder that:

(a) is copied to the Departmental Head; and

(b) has reference to the Radiation Safety Procedures, the duties of the Permit Holder in that respect, and the consequences of further infractions;

(c) will be communicated to all members of the Radiation Protection Committee.

2.9.3 On the third occurrence within a year of an offence, the Radiation Safety Officer shall inform the Chair of the Radiation Protection Committee.

2.9.4 The Chair will call an emergency ad hoc meeting of the Committee to be held within seven (7) days. The Chair will invite the Department Head and the Permit Holder. At this meeting, the Permit Holder will be required to show cause as to why the Internal Permit should not be revoked.

2.9.5 If a majority of the membership of the Radiation Protection Committee members in attendance is not satisfied that the Permit Holder has provided justification for retaining the permit, the permit will be revoked and the Environmental Health and Safety Office will dispose of all radioactive materials and lock-out any research X-ray equipment.

2.9.6 The Chair of the Radiation Protection Committee will notify the Dean of the appropriate Faculty and the Executive Director of Human Resources of the decision of the Committee.

2.9.7 The Radiation Protection Committee may decide to bypass one or more of the above noted steps if a serious violation occurs.

2.9.8 Notwithstanding any of the above actions, if it is the opinion of the Radiation Safety Officer that a serious, immediate risk to health, safety, environment or security exists, the Radiation Safety Officer shall have the authority to suspend operations or temporarily suspend a permit.

2.9.9 The Radiation Safety Officer will make a report on the situation, and the steps taken, to the Chair of the Radiation Protection Committee. The Chair of the Radiation Protection Committee will proceed as though this incident was a third occurrence within a year as outlined in 2.9.3.

3.0 Accountability

3.1 The University Secretary is responsible for advising the President that a formal review of this Procedure and Secondary Documents are required.

3.2 The Executive Director of Human Resources is responsible for the communication, administration and interpretation of this Procedure.

3.3 The Manager of the Environmental Health and Safety Office is responsible for the Radiation Safety Program and support to the Radiation Protection Committee.

3.4 All employees and students are accountable for complying with the Radiation Safety Governing Documents.

4.0 Review

4.1 Formal Procedure reviews will be conducted every ten (10) years. The next scheduled review date for this Procedure is August 26, 2021.

4.2 In the interim, these Procedures may be revised or rescinded if:

(a) the Vice-President (Administration) or the President deems necessary; or
(b) the relevant Policy is revised or rescinded.

5.0 Effect on Previous Statements

5.1 This Procedure supersedes:

(a) Procedure: Radiation Safety (April 1, 2004)

6.0 Cross References

Health and Safety Policy

Radiation Safety Policy