Module 8: Regulatory Requirements

8.1 Introduction

The possession, storage, use and disposal of radioactive materials is highly regulated at the international, federal, provincial, municipal and local (U of T) levels.

The United Nations established the International Atomic Energy Agency (IAEA) in 1956, with headquarters in Vienna (Austria). An important IAEA activity is to establish rules for international transport, use, and disposal of radioactive materials. However, their publications serve mostly as guidelines for each country. The agency has the power to control the enforcement of international treaties banning the use of nuclear technology for military purposes. Their safeguard inspectors also have the right to visit U of T and ask questions about the use, storage, and disposal of strategic radioactive materials.

In 1928, an international committee was formed to recommend radiation protection measures and to propose limits on radiation exposure. In 1950, the committee was reorganized and named the International Commission on Radiological Protection (ICRP). Recommendations from the ICRP are used as the basis for radiation protection programs in countries all over the world.

In Canada, the federal body with regulatory powers on all aspects of radiation safety is the Canadian Nuclear Safety Commission (CNSC). It exercises control over radioactive materials through the tenets of the Nuclear Safety and Control Act and enforces its mandate through a licence, report submissions, and regular inspections and audits. The CNSC also establishes federal dose equivalent standards for the public and nuclear energy workers all across Canada.

Other federal and provincial agencies are involved in the control of radioactive materials. These include Transport Canada, Health Canada, Environment Canada, Ontario Ministry of Health, and the Ontario Ministry of Labour.

8.2 Licensing and Permits

The main method for controlling the use of radioactive materials employed by the CNSC is the licensing system. The University of Toronto possesses a Nuclear Substances and Radiation Devices Licence. This type of licence allows considerable flexibility, which is required in a dynamic research centre such as U of T. It requires the University to maintain a well-managed and documented radiation protection program to ensure that radioactive materials are used safely.

The licence contains information about the federal and provincial acts and regulations for the use of radioactive materials. The Radiation Protection Service maintains copies of the licence. Any company that delivers radioisotopes to U of T must have a copy of this licence.

8.3 University of Toronto Radiation Protection Authority – UTRPA

The University of Toronto Radiation Protection Authority (UTRPA) is a committee composed of academics and administrators who are appointed by the U of T Governing Council. The UTRPA oversees the radiation protection program at U of T. It is the responsibility of the UTRPA to establish policies and procedures to ensure the safe use of radioactive materials in accordance with federal and provincial legislation.

Under the terms of the Nuclear Substances and Radiation Devices Licence, the UTRPA is responsible for authorizing qualified individuals to use radioactive materials and has the power to issue internal Radioisotope Permits.

8.3.1 UTRPA Responsibilities and Duties

  1. The UTRPA oversees all aspects of the radiation protection program at the U of T. Their control of the program is complete and all-embracing. The UTRPA has all necessary executive power delegated to it by the Governing Council to enforce and maintain the required standards of radiation protection necessary for a complex teaching and research institution.
  2. The responsibility of the UTRPA includes all sources of ionizing and non-ionizing radiation (from both materials and machines) on all properties owned or controlled by U of T.
  3. The UTRPA has the power to enforce and set standards through policies, inspections and disciplinary action, if necessary. It issues, administers, reviews, and amends Radioisotope Permits.
  4. Membership consists of academic personnel (including active permit holders) and administrative staff. It meets regularly to discuss and implement new radiation protection initiatives in the interest of improving the overall radiation safety program.
  5. The UTRPA maintains the radiation safety-training program to ensure that all users of radioactive materials receive appropriate training.
  6. The UTRPA considers and advises on, the establishment of radiation emergency measures within the university, as well as co-operation and integration with other authorities (CNSC, Police, etc.).

8.3.2 RPS Responsibilities and Duties

The UTRPA executes its mandate through the University of Toronto Radiation Protection Service (RPS). The RPS resides administratively within the Office of Environmental Health and Safety. The function of the RPS is to carry out the daily operation of the radiation safety program, as directed by the UTRPA.

Duties of the Radiation Protection Service include:

  1. Functioning as a link between the UTRPA and radioisotope users at the University of Toronto
  2. Reviewing the radiation safety manual, at least every two years
  3. Having major input in matters pertaining to:
  4. facility and equipment design
  5. work practices and procedures
  6. waste storage and disposal management
  7. evaluation, issuance and enforcement of internal Permits
  8. disciplinary action necessitated by non-compliance
  9. Organizing radiation safety training
  10. Preparing an Annual Report to the CNSC, as required by Regulatory Guide R-80 (or update)
  11. Acting as the contact for the institution with respect to licensing matters with the CNSC
  12. Being available for advice to radioisotope users on a full-time basis
  13. Establishing, implementing and maintaining a radiation safety control and assessment program in conjunction with the UTRPA
  14. Systematically and periodically reviewing survey programs for radiation and contamination levels in all areas where radioactive materials are found
  15. Ensuring the proper operation of the personnel monitoring program, including the bioassay program
  16. Ensuring that radiation safety instruments are available to the RPS in sufficient number and are calibrated and serviced as required
  17. Conducting a quarterly review of occupational radiation exposures and recommend ways of reducing exposures in the interest of the ALARA principle
  18. Supervising decontamination procedures, as necessary
  19. Ensuring that waste disposal procedures are in accordance with the conditions of the radioisotope license
  20. Ensuring that the necessary leak testing of sealed sources is performed
  21. Controlling the purchasing, use and disposal of radioactive materials through the issuance of internal Permits and the enforcement of Permit conditions
  22. Ensuring that appropriate radiation protection training is provided on a regular basis for all users and for those who regularly come into contact with radioactive materials
  23. Maintaining required records
  24. Ensuring that each internal Permit is amended when necessitated by changes to facilities, equipment, policies, isotopes, conditions of use or procedures
  25. Co-ordinating the development of plans to be used in the case of an emergency involving radioactive materials
  26. Investigating all overexposures, accidents and losses of radioactive materials and reporting them to the CNSC, when necessary
  27. Liaising with radioisotope users to ensure that doses of radiation are consistent with the ALARA principle

8.4 Responsibilities and Duties of Permit Holders and Radioisotope Users

8.4.1 Permit Holders

The Internal Permit Holders are responsible at all times for all aspects of radiation safety in areas under their supervision. They must provide adequate training of persons under their supervision in the proper use, handling, and storage of radioactive materials.

An applicant for a radioisotope permit must be a person experienced in working with radioactive materials. He/she must be a faculty member with the U of T, or otherwise acceptable to the UTRPA. Work with radioactive materials must be performed on the University properties or other properties under the control and authority of the U of T. A chart listing the criteria necessary to become a permit holder, along with an application form and other necessary information for obtaining a radioisotope permit has been prepared.

After completing the form, supporting documents establishing previous work experience with radioisotopes should be attached to the form. Both the applicant and Chair of the department under which the work will be performed must sign the form, and the signed form forwarded to the RPS. The Radiation Protection Officer in charge of new radioisotope permit approval and commissioning will visit the applicant and discuss the application. After all additional information (if any) is clarified, the application is sent to the Chair of the UTRPA.

After approval of the permit, purchasing of radioactive materials under that permit will be approved and work with radioactive materials can be begun. At the next UTRPA meeting, all applications for new radioisotope permits will be analyzed. If more information is necessary, it will be obtained from the applicant and the permit will be amended, if necessary.

Permit Holders must:

  1. Be responsible for the safe use of radioactive materials being stored and handled in radioisotope laboratories under their supervision
  2. Comply with all CNSC and UTRPA policies, procedures and permit conditions
  3. Ensure that staff and students are familiar with all relevant aspects of radiation safety, procedure and policy
  4. Provide specific training as required
  5. Be available to supervise students and oversee the daily operation of their radioisotope laboratories
  6. Establish specific work and storage areas for radioactive materials
  7. Provide personal protective equipment and dose surveillance, including Thermoluminescent Dosimeters where required, functional survey meter(s), appropriate shielding, laboratory coats, gloves and other personal safety supplies
  8. Keep an inventory of all radioactive materials and maintain a contamination monitoring program
  9. Report incidents

8.4.2 Radioisotope Users

Students, research associates, research assistants, technicians, etc. must:

  1. Work in compliance with all CNSC and UTRPA policies and procedures
  2. Understand and implement all relevant aspects of radiation safety, procedure and policy
  3. Ensure that work with radioactive materials does not create a hazard to themselves or others
  4. Use personal protective equipment such as laboratory coats and gloves
  5. Wear Thermoluminescent Dosimeters, when required
  6. Participate in the bioassay program, where required
  7. Perform contamination monitoring: Survey work areas and equipment for contamination after work, or at maximum within 7 days after use
  8. Record contamination survey results
  9. Record daily use of radioactive materials
  10. Follow all waste disposal procedures, ensuring that there are no releases of radioactive materials to the environment
  11. Record date of disposal
  12. Report any defective equipment or situations that may endanger themselves or others